Healthcare Provider Details

I. General information

NPI: 1083983944
Provider Name (Legal Business Name): E&T BEHAVIORAL ADVISORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N RAMONA BLVD SUITE 2
SAN JACINTO CA
92582-2567
US

IV. Provider business mailing address

31086 LARCHWOOD ST
MENIFEE CA
92584-8702
US

V. Phone/Fax

Practice location:
  • Phone: 718-551-1378
  • Fax: 951-487-2679
Mailing address:
  • Phone: 718-551-1378
  • Fax: 718-551-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA89851
License Number StateCA

VIII. Authorized Official

Name: MEHRAN MOTAMED
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 718-551-1378