Healthcare Provider Details

I. General information

NPI: 1922120963
Provider Name (Legal Business Name): GEORGE SOLOVJEV PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12665 GARDEN GROVE BLVD 714
GARDEN GROVE CA
92843-1901
US

IV. Provider business mailing address

151 KALMUS DR K-1
COSTA MESA CA
92626-5988
US

V. Phone/Fax

Practice location:
  • Phone: 714-620-8590
  • Fax: 714-620-8595
Mailing address:
  • Phone: 714-384-3870
  • Fax: 714-384-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY17567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: