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General NPI Number Information
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NPI Number | 1942409255
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGICAL ENRICHMENT CENTER
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Dates
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Enumeration Date | 07/16/2007
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Last Update Date | 07/16/2007
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Provider Practice Location Address
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Address Line | 2900 BRISTOL ST SUITE A108
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City | COSTA MESA
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State | CA
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Zip | 92626-5981
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Country | US
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Telephone | 714-432-0042
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Fax |
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Provider Business Mailing Address
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Address Line | 2900 BRISTOL ST SUITE A108
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City | COSTA MESA
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State | CA
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Zip | 92626-5981
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Country | US
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Telephone | 714-432-0042
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/PSYCHOLOGIST
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Name | DR. PAUL SULLIVAN
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Credential | PSY.D.
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Telephone | 714-432-0042
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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 | PSY18437
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License Number State | CA
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