Provider Demographics
NPI:1366787269
Name:SUPPORTIVE PSYCHOLOGICAL CARE
Entity type:Organization
Organization Name:SUPPORTIVE PSYCHOLOGICAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYRUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOAZAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:916-505-9151
Mailing Address - Street 1:9267 GREENBACK LN
Mailing Address - Street 2:B-98
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-4863
Mailing Address - Country:US
Mailing Address - Phone:916-505-9151
Mailing Address - Fax:916-988-7864
Practice Address - Street 1:9267 GREENBACK LN
Practice Address - Street 2:B98
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-4863
Practice Address - Country:US
Practice Address - Phone:916-505-9151
Practice Address - Fax:916-988-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13748261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health