Healthcare Provider Details

I. General information

NPI: 1942360748
Provider Name (Legal Business Name): STEVEN GRANT HERRICK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 E ELDER ST STE D
FALLBROOK CA
92028-3079
US

IV. Provider business mailing address

577 E ELDER ST STE D
FALLBROOK CA
92028-3079
US

V. Phone/Fax

Practice location:
  • Phone: 760-723-4911
  • Fax: 760-723-4694
Mailing address:
  • Phone: 760-723-4911
  • Fax: 760-723-4694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 10338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: