Provider Demographics
NPI:1003453804
Name:EMERALD SHORES PSYCHOLOGICAL CENTER
Entity Type:Organization
Organization Name:EMERALD SHORES PSYCHOLOGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JAFARI
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:949-231-9968
Mailing Address - Street 1:113 WATERWORKS WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3171
Mailing Address - Country:US
Mailing Address - Phone:949-436-9418
Mailing Address - Fax:760-859-3877
Practice Address - Street 1:113 WATERWORKS WAY STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3171
Practice Address - Country:US
Practice Address - Phone:949-436-9418
Practice Address - Fax:760-859-3877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-30
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty