Healthcare Provider Details

I. General information

NPI: 1790791705
Provider Name (Legal Business Name): WILLIAM LAFORGE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28362 VINCENT MORAGA DR STE C
TEMECULA CA
92590-3655
US

IV. Provider business mailing address

28362 VINCENT MORAGA DR STE C
TEMECULA CA
92590-3655
US

V. Phone/Fax

Practice location:
  • Phone: 951-699-9055
  • Fax: 951-699-8586
Mailing address:
  • Phone: 951-699-9055
  • Fax: 951-699-8586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY8015
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT9355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: