=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366787269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPPORTIVE PSYCHOLOGICAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2012
-----------------------------------------------------
Last Update Date | 12/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9267 GREENBACK LN B98
-----------------------------------------------------
City | ORANGEVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95662-4863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-505-9151
-----------------------------------------------------
Fax | 916-988-7864
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9267 GREENBACK LN B-98
-----------------------------------------------------
City | ORANGEVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95662-4863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-505-9151
-----------------------------------------------------
Fax | 916-988-7864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CYRUS MOAZAM
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 916-505-9151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | PSY13748
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------