Healthcare Provider Details

I. General information

NPI: 1508031006
Provider Name (Legal Business Name): SPECTRUM, THERAPY, ASSESSMENT, REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 CAROLINIAN DR
SUMMERVILLE SC
29485-7854
US

IV. Provider business mailing address

246 CAROLINIAN DR
SUMMERVILLE SC
29485-7854
US

V. Phone/Fax

Practice location:
  • Phone: 949-322-6316
  • Fax:
Mailing address:
  • Phone: 949-322-6316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number2008-071908
License Number StateSC

VIII. Authorized Official

Name: MS. ZAHRA JUNE HAJIAGHAMOHSENI
Title or Position: BEHAVIOR ANALYST
Credential: M.S.
Phone: 843-532-8349