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General NPI Number Information
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NPI Number | 1174754634
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Entity Type | Individual
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Provider Name | EDWARD JAMES PALLOTTA JR. PH.D.
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Gender | Male
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Dates
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Enumeration Date | 07/31/2009
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Last Update Date | 04/20/2020
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Provider Practice Location Address
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Address Line | 14081 YORBA ST STE 203
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City | TUSTIN
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State | CA
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Zip | 92780-2011
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Country | US
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Telephone | 949-743-5900
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Fax | 949-203-2877
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Provider Business Mailing Address
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Address Line | 14081 YORBA ST STE 203
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City | TUSTIN
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State | CA
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Zip | 92780-2011
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Country | US
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Telephone | 949-743-5900
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Fax | 949-203-2877
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY25244
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License Number State | CA
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