Healthcare Provider Details

I. General information

NPI: 1558597146
Provider Name (Legal Business Name): AFFILIATED PSYCHIATRIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 CAMINO DE LOS MARES #226
SAN CLEMENTE CA
92673-2807
US

IV. Provider business mailing address

647 CAMINO DE LOS MARES #226
SAN CLEMENTE CA
92673-2807
US

V. Phone/Fax

Practice location:
  • Phone: 949-489-9898
  • Fax: 949-489-2569
Mailing address:
  • Phone: 949-489-9898
  • Fax: 949-489-2569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14002
License Number StateCA

VIII. Authorized Official

Name: DR. ESTHER EDITH SELLERS
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D
Phone: 949-489-9898