=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831685197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNRISE PSYCHOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2018
-----------------------------------------------------
Last Update Date | 07/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 729 SUNRISE AVE STE 101
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-782-3800
-----------------------------------------------------
Fax | 916-782-3820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 SUNRISE AVE STE 101
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-4504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-782-3800
-----------------------------------------------------
Fax | 916-782-3820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | STEPHEN GARY MCCLURE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 916-782-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY13572
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------