MEDICARE: GOLDEN COAST PSYCHOLOGY CENTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1275150419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN COAST PSYCHOLOGY CENTER

Provider Business Mailing Address
First Line	:	3151 AIRWAY AVE STE A2
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-4620
Country	:	US
Telephone Number	:	951-323-3729
Fax Number	:	949-377-3940

Provider Business Practice Location Address
First Line	:	3151 AIRWAY AVE STE A2
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-4620
Country	:	US
Telephone Number	:	951-323-3729
Fax Number	:	949-377-3940

Authorized Official
Title or Position	:	CEO
Name	:	MISS MARLENE CUEVAS
Credential	:	LCSW
Telephone Number	:	951-323-3729

Provider Enumeration Date	:	07/04/2020
Last Update Date	:	07/04/2020

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