Healthcare Provider Details

I. General information

NPI: 1306057260
Provider Name (Legal Business Name): JOSE MARCOS LAFOSSE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 CENTRE ST STE 104
SAN DIEGO CA
92103-2655
US

IV. Provider business mailing address

4251 KIPLING ST UNIT 565
WHEAT RIDGE CO
80033-2899
US

V. Phone/Fax

Practice location:
  • Phone: 858-964-0722
  • Fax: 866-437-0375
Mailing address:
  • Phone: 720-965-0055
  • Fax: 720-799-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2278
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2278
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2278
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: