MEDICARE: FLORENCE GRIFFITH JOYNER YOUTH FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	LMFT83318	CA

General Provider Information

NPI Number	:	1598161325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORENCE GRIFFITH JOYNER YOUTH FOUNDATION

Provider Business Mailing Address
First Line	:	3093 CENTRAL AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-4030
Country	:	US
Telephone Number	:	619-284-2443
Fax Number	:

Provider Business Practice Location Address
First Line	:	3093 CENTRAL AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-4030
Country	:	US
Telephone Number	:	619-284-2443
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. ELIZABETH TATE
Credential	:	MA, LMFT
Telephone Number	:	619-284-2443

Provider Enumeration Date	:	11/05/2014
Last Update Date	:	11/05/2014

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