Healthcare Provider Details

I. General information

NPI: 1760631899
Provider Name (Legal Business Name): DEREK TODD SCHWARTZ PH.D, BCIAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8813 VILLA LA JOLLA DR STE. 2002
LA JOLLA CA
92037-1937
US

IV. Provider business mailing address

8813 VILLA LA JOLLA DR STE. 2002
LA JOLLA CA
92037-1937
US

V. Phone/Fax

Practice location:
  • Phone: 858-877-0770
  • Fax: 858-452-1517
Mailing address:
  • Phone: 858-877-0770
  • Fax: 858-452-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY22176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: