Healthcare Provider Details

I. General information

NPI: 1972876332
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA PSYCHODIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2698 MATARO ST
PASADENA CA
91107-3416
US

IV. Provider business mailing address

2698 MATARO ST
PASADENA CA
91107-3416
US

V. Phone/Fax

Practice location:
  • Phone: 626-773-3300
  • Fax: 626-773-3333
Mailing address:
  • Phone: 626-773-3300
  • Fax: 626-773-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. MARTIN V ROSS
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 626-773-3300