Healthcare Provider Details

I. General information

NPI: 1356637185
Provider Name (Legal Business Name): SAURABH GUPTA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SYRUS GUPTA PH.D.

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 OLD TOWN AVE STE. A-208
SAN DIEGO CA
92110-2930
US

IV. Provider business mailing address

3990 OLD TOWN AVE STE. A-208
SAN DIEGO CA
92110-2930
US

V. Phone/Fax

Practice location:
  • Phone: 619-537-9345
  • Fax: 619-269-9245
Mailing address:
  • Phone: 619-537-9345
  • Fax: 619-269-9245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY24218
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY24218
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24218
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY24218
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY24218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: