Healthcare Provider Details

I. General information

NPI: 1346585908
Provider Name (Legal Business Name): SOUTH COUNTY PSYCHOLOGICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23832 ROCKFIELD BLVD STE 130
LAKE FOREST CA
92630-2860
US

IV. Provider business mailing address

23832 ROCKFIELD BLVD STE 130
LAKE FOREST CA
92630-2860
US

V. Phone/Fax

Practice location:
  • Phone: 949-297-6680
  • Fax: 949-861-6321
Mailing address:
  • Phone: 949-297-6680
  • Fax: 949-861-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPSY22415
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberPSY22415
License Number StateCA

VIII. Authorized Official

Name: DR. SUSAN JOY NOVAK
Title or Position: PRESIDENT/CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 949-297-6680