Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | PSY13748 | CA |
Y | 103TB0200X | Cognitive & Behavioral Psychologist | PSY13748 | CA |
N | 103G00000X | Clinical Psychologist | PSY13748 | CA |
N | 103TC0700X | Clinical Psychologist | PSY13748 | CA |
N | 103TC1900X | Counseling Psychologist | PSY13748 | CA |
N | 103TF0200X | Forensic Psychologist | PSY13748 | CA |
N | 103TM1800X | Intellectual & Developmental Disabilities | PSY13748 | CA |
NPI | 1558574814 |
---|---|
Provider Name | Cyrus A Moazam |
First Address | Folsom, CA 95630-6242 |
Second Address | Orangevale, CA 95662-4863 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 20/04/2012 |