Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0004X | Health Psychologist | 953389108 | CA |
NPI | 1619420858 |
---|---|
Provider Name | Michael Surban |
First Address | Long Beach, CA 90806-4312 |
Second Address | Long Beach, CA 90806-4312 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2016 |
Last Update Date | 24/07/2016 |