MEDICARE: GOLDEN STATE PSYCHOLOGICAL SERVICES, 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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1528523321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN STATE PSYCHOLOGICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	12658 TIARA ST # 1
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-1023
Country	:	US
Telephone Number	:	818-943-8899
Fax Number	:

Provider Business Practice Location Address
First Line	:	12658 TIARA ST # 1
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-1023
Country	:	US
Telephone Number	:	818-943-8899
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANNA LEVI
Credential	:
Telephone Number	:	818-943-8899

Provider Enumeration Date	:	02/05/2019
Last Update Date	:	02/05/2019

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