Healthcare Provider Details

I. General information

NPI: 1497895601
Provider Name (Legal Business Name): RAPHAEL ZIEGLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 S PACIFIC COAST HWY SUITE 102
REDONDO BEACH CA
90277-4765
US

IV. Provider business mailing address

326 S PACIFIC COAST HWY STE 200
REDONDO BEACH CA
90277-3769
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-3288
  • Fax: 310-855-3498
Mailing address:
  • Phone: 310-855-3288
  • Fax: 310-855-3498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY21258
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY21258
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY21258
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY21258
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: