Healthcare Provider Details

I. General information

NPI: 1255563433
Provider Name (Legal Business Name): SKULTIP SIRIKANTRAPORN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5348 UNIVERSITY AVE SUITE 101
SAN DIEGO CA
92105-8025
US

IV. Provider business mailing address

5348 UNIVERSITY AVE SUITE 101
SAN DIEGO CA
92105-8025
US

V. Phone/Fax

Practice location:
  • Phone: 619-229-2999
  • Fax:
Mailing address:
  • Phone: 619-229-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25612
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number019363
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: