Healthcare Provider Details

I. General information

NPI: 1821601451
Provider Name (Legal Business Name): JOSHUA CRAIG PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 CHICAGO AVE STE M17
RIVERSIDE CA
92507-2033
US

IV. Provider business mailing address

1660 CHICAGO AVE STE M17
RIVERSIDE CA
92507-2033
US

V. Phone/Fax

Practice location:
  • Phone: 310-696-9019
  • Fax:
Mailing address:
  • Phone: 310-696-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY30442
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30442
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: