MEDICARE: MR. EDWARD WILLIAM REICKS PH,D,

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY 11010	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPL 11010	OTHER	CA	USBH
2	PSY 11010	OTHER	CA	STATE LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083768733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDWARD WILLIAM REICKS PH,D,

Provider Business Mailing Address
First Line	:	1440 N HARBOR BLVD
Second Line	:	SUITE 127
City	:	FULLERTON
State	:	CA
Zip	:	92835-4127
Country	:	US
Telephone Number	:	714-879-7091
Fax Number	:	714-441-0914

Provider Business Practice Location Address
First Line	:	1440 N HARBOR BLVD
Second Line	:	SUITE 127
City	:	FULLERTON
State	:	CA
Zip	:	92835-4114
Country	:	US
Telephone Number	:	714-879-7091
Fax Number	:	714-441-0914

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	02/02/2012

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