Provider Demographics
NPI:1912186628
Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PROFESSOR
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIGAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-824-1812
Mailing Address - Street 1:19722 MACARTHUR BLVD
Mailing Address - Street 2:UCI-CHILD DEVELOPMENT CENTER
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2404
Mailing Address - Country:US
Mailing Address - Phone:949-824-1800
Mailing Address - Fax:949-824-1811
Practice Address - Street 1:19722 MACARTHUR BLVD
Practice Address - Street 2:UCI-CHILD DEVELOPMENT CENTER
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2404
Practice Address - Country:US
Practice Address - Phone:949-824-1800
Practice Address - Fax:949-824-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14209103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty