Healthcare Provider Details

I. General information

NPI: 1790213247
Provider Name (Legal Business Name): PASADENA CLINICAL GROUP, A PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 E COLORADO BLVD STE 428
PASADENA CA
91101-2058
US

IV. Provider business mailing address

PO BOX 5581
PASADENA CA
91117-0581
US

V. Phone/Fax

Practice location:
  • Phone: 626-354-6440
  • Fax: 805-456-5547
Mailing address:
  • Phone: 626-354-6440
  • Fax: 805-456-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: VINCENZO ISRAEL PICCIRILLO
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 626-354-6440