Healthcare Provider Details

I. General information

NPI: 1649911231
Provider Name (Legal Business Name): SORRENTO PSYCHOLOGICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 LUSK BLVD STE C159
SAN DIEGO CA
92121-2684
US

IV. Provider business mailing address

6540 LUSK BLVD STE C159
SAN DIEGO CA
92121-2684
US

V. Phone/Fax

Practice location:
  • Phone: 858-800-2236
  • Fax: 844-794-7581
Mailing address:
  • Phone: 858-800-2236
  • Fax: 844-794-7581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOD PENG
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 858-800-2236