Healthcare Provider Details

I. General information

NPI: 1376141440
Provider Name (Legal Business Name): AVANT GARDE PSYCHOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 E COAST HWY STE F
CORONA DEL MAR CA
92625-2110
US

IV. Provider business mailing address

28292 EL SUR
LAGUNA NIGUEL CA
92677-4422
US

V. Phone/Fax

Practice location:
  • Phone: 949-412-7178
  • Fax:
Mailing address:
  • Phone: 949-412-7178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE VALERE ESTONACTOC
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 949-412-7178