MEDICARE: CROSSROADS PSYCHOTHERAPY GROUP INC.

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

General Provider Information

NPI Number	:	1467409516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS PSYCHOTHERAPY GROUP INC.

Provider Business Mailing Address
First Line	:	16033 BOLSA CHICA ST
Second Line	:	SUITE #104-239
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-2452
Country	:	US
Telephone Number	:	714-846-8230
Fax Number	:	714-840-6508

Provider Business Practice Location Address
First Line	:	6615 E PACIFIC COAST HWY
Second Line	:	SUITE #115
City	:	LONG BEACH
State	:	CA
Zip	:	90803-4211
Country	:	US
Telephone Number	:	562-596-0090
Fax Number	:	562-596-0094

Authorized Official
Title or Position	:	CEO/ CLINICAL PSYCHOLOGIST
Name	:	DR. DEBORAH G. MATHER
Credential	:	PH.D.
Telephone Number	:	714-846-8230

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	08/14/2013

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