Healthcare Provider Details

I. General information

NPI: 1083928980
Provider Name (Legal Business Name): PATRICIA ROCIO PERALES HUERTA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N ECKHOFF ST
ORANGE CA
92868-1008
US

IV. Provider business mailing address

800 N ECKHOFF ST
ORANGE CA
92868-1008
US

V. Phone/Fax

Practice location:
  • Phone: 562-774-1646
  • Fax:
Mailing address:
  • Phone: 562-774-1646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number29890
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: