Healthcare Provider Details

I. General information

NPI: 1932621216
Provider Name (Legal Business Name): NEWPORT PSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 CORPORATE PLAZA DR STE 150
NEWPORT BEACH CA
92660
US

IV. Provider business mailing address

23 CORPORATE PLAZA DR STE 150
NEWPORT BEACH CA
92660-7908
US

V. Phone/Fax

Practice location:
  • Phone: 949-887-2007
  • Fax:
Mailing address:
  • Phone: 949-887-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number26906
License Number StateCA

VIII. Authorized Official

Name: DR. EILEEN PANIAGUA
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 949-887-2007