Healthcare Provider Details

I. General information

NPI: 1063053726
Provider Name (Legal Business Name): DR. NASTASSIA REBECCA RISER, A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 GARDEN VIEW CT STE 201J
ENCINITAS CA
92024-2479
US

IV. Provider business mailing address

700 GARDEN VIEW CT STE 201J
ENCINITAS CA
92024-2479
US

V. Phone/Fax

Practice location:
  • Phone: 760-492-9057
  • Fax:
Mailing address:
  • Phone: 760-492-9057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. REBECCA (NASTASSIA) E RISER
Title or Position: CLINICAL DIRECTOR
Credential: M.S., PH.D.
Phone: 760-492-9057