Healthcare Provider Details

I. General information

NPI: 1578873584
Provider Name (Legal Business Name): JOSE ANTONIO CHOLULA BRUNO MA, EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CABRILLO PARK DR SUITE 300
SANTA ANA CA
92701-5017
US

IV. Provider business mailing address

525 CABRILLO PARK DR SUITE 300
SANTA ANA CA
92701-5017
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax: 714-547-8856
Mailing address:
  • Phone: 714-953-4455
  • Fax: 714-547-8856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY32179
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: