Provider Demographics
NPI:1437358520
Name:PSYCHSHIELD CORPORATION
Entity Type:Organization
Organization Name:PSYCHSHIELD CORPORATION
Other - Org Name:PSYCHSHIELD BEHAVIORAL HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PSYCHOTHERAPY PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:562-595-7102
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90714-0250
Mailing Address - Country:US
Mailing Address - Phone:562-595-7102
Mailing Address - Fax:562-595-9112
Practice Address - Street 1:4000 LONG BEACH BLVD STE 212
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2617
Practice Address - Country:US
Practice Address - Phone:562-595-7102
Practice Address - Fax:562-595-9112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 4467261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHD 019 00 NOtherBLUE SHIELD OF CALIFORNIA