Healthcare Provider Details

I. General information

NPI: 1669289740
Provider Name (Legal Business Name): DAVID SISAK BELJAEV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8107 WHITNEY DR
RIVERSIDE CA
92509-5209
US

IV. Provider business mailing address

8107 WHITNEY DR
RIVERSIDE CA
92509-5209
US

V. Phone/Fax

Practice location:
  • Phone: 818-434-1753
  • Fax:
Mailing address:
  • Phone: 818-434-1753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: