Provider Demographics
NPI:1174754634
Name:PALLOTTA, EDWARD JAMES JR (PHD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:PALLOTTA
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14081 YORBA ST STE 203
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2011
Mailing Address - Country:US
Mailing Address - Phone:949-743-5900
Mailing Address - Fax:949-203-2877
Practice Address - Street 1:14081 YORBA ST STE 203
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2011
Practice Address - Country:US
Practice Address - Phone:949-743-5900
Practice Address - Fax:949-203-2877
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25244103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical