Healthcare Provider Details

I. General information

NPI: 1568757185
Provider Name (Legal Business Name): THE PALAVRA TREE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2878 IMPERIAL AVE
SAN DIEGO CA
92102-4026
US

IV. Provider business mailing address

2878 IMPERIAL AVE
SAN DIEGO CA
92102-4026
US

V. Phone/Fax

Practice location:
  • Phone: 619-238-7393
  • Fax: 619-696-0492
Mailing address:
  • Phone: 619-263-7768
  • Fax: 619-262-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number370102BN
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. DENISE R REED
Title or Position: EXECUTIVE DIRECTOR
Credential: B.S.
Phone: 619-263-7768