Healthcare Provider Details

I. General information

NPI: 1073026118
Provider Name (Legal Business Name): COLLABORATIVE PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2017
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 OLD TOWN AVE STE 106C
SAN DIEGO CA
92110-2968
US

IV. Provider business mailing address

3990 OLD TOWN AVE STE 106C
SAN DIEGO CA
92110-2968
US

V. Phone/Fax

Practice location:
  • Phone: 858-766-1179
  • Fax:
Mailing address:
  • Phone: 858-766-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. LAUREN WOOLLEY
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 858-766-1179