Provider Demographics
NPI:1841252798
Name:PROUD, ERNEST JR (PHD)
Entity type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:
Last Name:PROUD
Suffix:JR
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 1:8118 E SAN LUIS DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-5657
Mailing Address - Country:US
Mailing Address - Phone:714-997-9942
Mailing Address - Fax:714-517-9189
Practice Address - Street 1:8118 E SAN LUIS DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-5657
Practice Address - Country:US
Practice Address - Phone:714-997-9942
Practice Address - Fax:714-517-9189
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6759103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist