Basic Information
| Provider Information | |||||||||
| NPI: | 1902155997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECERRA | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | ANTONIO | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 CABRILLO PARK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927015017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149534455 | ||||||||
| FaxNumber: | 7145422793 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 CABRILLO PARK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149534455 | ||||||||
| FaxNumber: | 7145422793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225C00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | 103TC2200X | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 7068 | 05 | CA | MEDICAID | 7420 | 05 | CA | MEDICAID |