Healthcare Provider Details

I. General information

NPI: 1629615174
Provider Name (Legal Business Name): WHOLE PSYCHOLOGY OF SAN DIEGO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 UNIVERSITY AVE STE E107 #720
SAN DIEGO CA
92103
US

IV. Provider business mailing address

1050 UNIVERSITY AVE STE E107 #720
SAN DIEGO CA
92103
US

V. Phone/Fax

Practice location:
  • Phone: 805-679-3677
  • Fax:
Mailing address:
  • Phone: 805-679-3677
  • Fax:

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

VIII. Authorized Official

Name: MICHELLE PITTS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 805-679-3677