Healthcare Provider Details

I. General information

NPI: 1144770207
Provider Name (Legal Business Name): DEISY C. BOSCAN PH.D. PSYCHOLOGIST PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7590 FAY AVE STE 401
LA JOLLA CA
92037-4872
US

IV. Provider business mailing address

PO BOX 2583
LA JOLLA CA
92038-2583
US

V. Phone/Fax

Practice location:
  • Phone: 858-263-4226
  • Fax: 858-263-4206
Mailing address:
  • Phone: 858-263-4226
  • Fax: 858-263-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18873
License Number StateCA

VIII. Authorized Official

Name: DEISY CRISTINA BOSCAN
Title or Position: OWNER
Credential: PHD
Phone: 858-263-4226