Healthcare Provider Details

I. General information

NPI: 1598277469
Provider Name (Legal Business Name): SO CAL PSYCHOLOGY SERVICES APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34249 CAMINO CAPISTRANO STE 101
CAPO BEACH CA
92624-1138
US

IV. Provider business mailing address

34249 CAMINO CAPISTRANO STE 101
CAPO BEACH CA
92624-1138
US

V. Phone/Fax

Practice location:
  • Phone: 949-542-3874
  • Fax: 949-484-7021
Mailing address:
  • Phone: 949-542-3874
  • Fax: 949-484-7021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MYRNA FERNANDEZ
Title or Position: OFFICE MANAGER
Credential: LPT
Phone: 949-542-3874