Basic Information
| Provider Information | |||||||||
| NPI: | 1295717551 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENTS UCDPBG NEUR PSYC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REGENTS UCDPBG NEUR PSYC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 BROADWAY | ||||||||
| Address2: | SUITE 2600 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167349200 | ||||||||
| FaxNumber: | 9167349336 | ||||||||
| Practice Location | |||||||||
| Address1: | 4860 Y ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343588 | ||||||||
| FaxNumber: | 9164522739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCGOWAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9167349129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | GPS000040 | 05 | CA | MEDICAID |