Provider Demographics
NPI:1982803557
Name:DANIEL, COLLEEN (PSYD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30211 AVENIDA DE LAS BANDERA STE 200
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2159
Mailing Address - Country:US
Mailing Address - Phone:657-223-1690
Mailing Address - Fax:
Practice Address - Street 1:4902 IRVINE CENTER DR STE 104
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3334
Practice Address - Country:US
Practice Address - Phone:949-614-0098
Practice Address - Fax:760-859-3877
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23849103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY23849OtherBOARD OF PSYCHOLOGY