Healthcare Provider Details

I. General information

NPI: 1487703385
Provider Name (Legal Business Name): BEHAVIORAL HEALTH ASSOCIATES MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4542 RUFFNER ST SUITE 200
SAN DIEGO CA
92111-2237
US

IV. Provider business mailing address

4542 RUFFNER ST SUITE 200
SAN DIEGO CA
92111-2237
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-4600
  • Fax: 619-528-4625
Mailing address:
  • Phone: 619-528-4600
  • Fax: 619-528-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER GUDE
Title or Position: CREDENTIALING MANAGER
Credential: M.A.
Phone: 619-528-4600