=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598277469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SO CAL PSYCHOLOGY SERVICES APC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2017
-----------------------------------------------------
Last Update Date | 10/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34249 CAMINO CAPISTRANO STE 101
-----------------------------------------------------
City | CAPO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92624-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-542-3874
-----------------------------------------------------
Fax | 949-484-7021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34249 CAMINO CAPISTRANO STE 101
-----------------------------------------------------
City | CAPO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92624-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-542-3874
-----------------------------------------------------
Fax | 949-484-7021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MYRNA FERNANDEZ
-----------------------------------------------------
Credential | LPT
-----------------------------------------------------
Telephone | 949-542-3874
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------