Provider Demographics
NPI:1346585908
Name:SOUTH COUNTY PSYCHOLOGICAL, INC.
Entity Type:Organization
Organization Name:SOUTH COUNTY PSYCHOLOGICAL, INC.
Other - Org Name:SUSAN J. NOVAK, PHD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-297-6680
Mailing Address - Street 1:23832 ROCKFIELD BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2860
Mailing Address - Country:US
Mailing Address - Phone:949-297-6680
Mailing Address - Fax:949-861-6321
Practice Address - Street 1:23832 ROCKFIELD BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2860
Practice Address - Country:US
Practice Address - Phone:949-297-6680
Practice Address - Fax:949-861-6321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22415261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health