Healthcare Provider Details

I. General information

NPI: 1528856531
Provider Name (Legal Business Name): SOUL TIDE PSYCHOTHERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3257 CAMINO DE LOS COCHES
CARLSBAD CA
92009-8976
US

IV. Provider business mailing address

2204 IRVING AVE
SAN DIEGO CA
92113-2301
US

V. Phone/Fax

Practice location:
  • Phone: 858-945-7421
  • Fax:
Mailing address:
  • Phone: 858-945-7421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TREVOR OLSON
Title or Position: SECRETARY
Credential: PSY.D.
Phone: 858-945-7421