Healthcare Provider Details

I. General information

NPI: 1083003586
Provider Name (Legal Business Name): SAN DIEGO PSYCHOLOGICAL CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 10/09/2021
Certification Date: 10/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD SUITE B3
POWAY CA
92064-2435
US

IV. Provider business mailing address

2258 SUNSET DR
ESCONDIDO CA
92025-6613
US

V. Phone/Fax

Practice location:
  • Phone: 760-607-6463
  • Fax: 760-607-3433
Mailing address:
  • Phone: 760-607-6463
  • Fax: 760-607-3433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number22844
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. BANAFSHEH PEZESHK
Title or Position: CEO
Credential: PSY.D
Phone: 760-607-6463