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General NPI Number Information
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NPI Number | 1376141440
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Entity Type | Organization
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Legal Business Name | AVANT GARDE PSYCHOLOGY INC
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Dates
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Enumeration Date | 10/12/2020
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Last Update Date | 10/12/2020
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Provider Practice Location Address
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Address Line | 2737 E COAST HWY STE F
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City | CORONA DEL MAR
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State | CA
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Zip | 92625-2110
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Country | US
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Telephone | 949-412-7178
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Fax |
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Provider Business Mailing Address
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Address Line | 28292 EL SUR
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City | LAGUNA NIGUEL
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State | CA
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Zip | 92677-4422
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Country | US
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Telephone | 949-412-7178
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. GEORGE VALERE ESTONACTOC
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Credential | PH.D.
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Telephone | 949-412-7178
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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