Healthcare Provider Details

I. General information

NPI: 1609296086
Provider Name (Legal Business Name): DR HAYGOUSH KALINIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30320 RANCHO VIEJO RD ST 5
SAN JUAN CAPISTRANO CA
92675-1581
US

IV. Provider business mailing address

30320 RANCHO VIEJO RD ST 5
SAN JUAN CAPISTRANO CA
92675-1581
US

V. Phone/Fax

Practice location:
  • Phone: 949-481-8414
  • Fax: 949-481-8415
Mailing address:
  • Phone: 949-481-8414
  • Fax: 949-481-8415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY20155
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY20155
License Number StateCA

VIII. Authorized Official

Name: DR. HAYGOUSH KALINIAN
Title or Position: NEUROPSYCHOLOGIT
Credential: PHD
Phone: 949-481-8414