Provider Demographics
NPI:1083672877
Name:RALPH, NORBERT (PHD)
Entity Type:Individual
Prefix:
First Name:NORBERT
Middle Name:
Last Name:RALPH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4978
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4978
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:
Practice Address - Street 1:519 ESTUDILLO AVE
Practice Address - Street 2:#N
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4690
Practice Address - Country:US
Practice Address - Phone:209-575-4575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5907103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY059070Medicaid
CAPSY059070Medicaid
CA00PL59070Medicare PIN