Healthcare Provider Details

I. General information

NPI: 1528676269
Provider Name (Legal Business Name): TRAUMA & STRESS RECOVERY, A MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 12TH ST STE 110
OAKLAND CA
94607-4005
US

IV. Provider business mailing address

500 12TH ST STE 110
OAKLAND CA
94607-4005
US

V. Phone/Fax

Practice location:
  • Phone: 415-346-8640
  • Fax: 415-563-2273
Mailing address:
  • Phone: 415-346-8640
  • Fax: 415-563-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIAN ASUELO
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 415-346-8640