MEDICARE: SO CAL PSYCHOLOGY SERVICES APC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	103TF0000X	Family Psychologist
4	261QM0850X	Adult Mental Health Clinic/Center
5	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1598277469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SO CAL PSYCHOLOGY SERVICES APC

Provider Business Mailing Address
First Line	:	34249 CAMINO CAPISTRANO STE 101
Second Line	:
City	:	CAPO BEACH
State	:	CA
Zip	:	92624-1138
Country	:	US
Telephone Number	:	949-542-3874
Fax Number	:	949-484-7021

Provider Business Practice Location Address
First Line	:	34249 CAMINO CAPISTRANO STE 101
Second Line	:
City	:	CAPO BEACH
State	:	CA
Zip	:	92624-1138
Country	:	US
Telephone Number	:	949-542-3874
Fax Number	:	949-484-7021

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MYRNA FERNANDEZ
Credential	:	LPT
Telephone Number	:	949-542-3874

Provider Enumeration Date	:	10/31/2017
Last Update Date	:	10/31/2017

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