Healthcare Provider Details

I. General information

NPI: 1841363801
Provider Name (Legal Business Name): AUGUSTUS LIEVANOS JR. PSYCHOLOGY DOCTORATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 E CHAPMAN AVE # 318
ORANGE CA
92869-3812
US

IV. Provider business mailing address

3419 E CHAPMAN AVE # 318
ORANGE CA
92869-3812
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6363
  • Fax: 714-935-8112
Mailing address:
  • Phone: 714-935-6363
  • Fax: 714-935-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 19059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: