Healthcare Provider Details

I. General information

NPI: 1760922991
Provider Name (Legal Business Name): OCEANSIDE PSYCHOLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 YACHT CLUB WAY STE A6
REDONDO BEACH CA
90277-6907
US

IV. Provider business mailing address

P.O. BOX 3453
REDONDO BEACH CA
90277
US

V. Phone/Fax

Practice location:
  • Phone: 310-956-1406
  • Fax: 424-262-1008
Mailing address:
  • Phone: 310-956-1406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY27868
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: URVI NATHA
Title or Position: CLINICAL DIRECTOR/CEO
Credential: PSY.D.
Phone: 310-944-1058