Healthcare Provider Details

I. General information

NPI: 1104183292
Provider Name (Legal Business Name): SOCAL CENTER FOR CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 E CHAPMAN AVE SUITE 204
ORANGE CA
92866-2139
US

IV. Provider business mailing address

1110 E CHAPMAN AVE SUITE 204
ORANGE CA
92866-2139
US

V. Phone/Fax

Practice location:
  • Phone: 714-453-0688
  • Fax: 714-453-0691
Mailing address:
  • Phone: 714-453-0688
  • Fax: 714-453-0691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. GEOFFREY PHILLIPS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-453-0688