Healthcare Provider Details

I. General information

NPI: 1174768014
Provider Name (Legal Business Name): CONSTANCE JEAN DALENBERG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3252 HOLIDAY CT SUITE 209
LA JOLLA CA
92037-0027
US

IV. Provider business mailing address

3252 HOLIDAY CT SUITE 209
LA JOLLA CA
92037-0027
US

V. Phone/Fax

Practice location:
  • Phone: 619-606-0440
  • Fax:
Mailing address:
  • Phone: 619-606-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY11952
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY11952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: