Basic Information
| Provider Information | |||||||||
| NPI: | 1265980882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROFFITT | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 W LA VETA AVE | ||||||||
| Address2: | SUITE 470 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145098481 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1120 W LA VETA AVE | ||||||||
| Address2: | SUITE 470 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145098481 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2016 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 32967 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.