Provider Demographics
NPI:1558597146
Name:AFFILIATED PSYCHIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:AFFILIATED PSYCHIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:EDITH
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-489-9898
Mailing Address - Street 1:647 CAMINO DE LOS MARES
Mailing Address - Street 2:#226
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2807
Mailing Address - Country:US
Mailing Address - Phone:949-489-9898
Mailing Address - Fax:949-489-2569
Practice Address - Street 1:647 CAMINO DE LOS MARES
Practice Address - Street 2:#226
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2807
Practice Address - Country:US
Practice Address - Phone:949-489-9898
Practice Address - Fax:949-489-2569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14002103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY140020Medicaid
CAPSY140020Medicaid
CALP14002-BMedicare UPIN