MEDICARE: DR. ELISA FLORES CORRALES PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY27862	CA
2	103TC2200X	Clinical Child & Adolescent Psychologist	PSY27862	CA
3	103T00000X	Psychologist	PSY27862	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY27862	OTHER	CA	CA PSYCHOLOGY LICENSE

General Provider Information

NPI Number	:	1508981846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISA FLORES CORRALES PH.D

Provider Business Mailing Address
First Line	:	1201 W LA VETA AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4203
Country	:	US
Telephone Number	:	714-509-8481
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 W LA VETA AVE STE 660 & STE 470
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4244
Country	:	US
Telephone Number	:	714-509-8481
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	10/18/2023

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