Healthcare Provider Details

I. General information

NPI: 1225696792
Provider Name (Legal Business Name): MICHAEL FEDIDA SCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W 5TH ST BLDG 38C
SANTA ANA CA
92701-4599
US

IV. Provider business mailing address

405 W 5TH ST BLDG 38C
SANTA ANA CA
92701-4599
US

V. Phone/Fax

Practice location:
  • Phone: 714-796-0324
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: