MEDICARE: CENTRO DE PSICOLOGIA CULTURAL, INC

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	103T00000X	Psychologist	19752	CA

General Provider Information

NPI Number	:	1770898298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO DE PSICOLOGIA CULTURAL, INC

Provider Business Mailing Address
First Line	:	6136 MISSION GORGE RD
Second Line	:	SUITE 129
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3494
Country	:	US
Telephone Number	:	619-282-4270
Fax Number	:	619-282-4272

Provider Business Practice Location Address
First Line	:	6136 MISSION GORGE RD
Second Line	:	SUITE 129
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3494
Country	:	US
Telephone Number	:	619-282-4270
Fax Number	:	619-282-4272

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SONIA I. CARBONELL
Credential	:
Telephone Number	:	619-282-4270

Provider Enumeration Date	:	08/09/2010
Last Update Date	:	08/09/2010

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