Healthcare Provider Details

I. General information

NPI: 1366040396
Provider Name (Legal Business Name): LIFEOLOGIE SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3295 MEADE AVE
SAN DIEGO CA
92116-4557
US

IV. Provider business mailing address

3188 FRANKLIN AVE
SAN DIEGO CA
92113-1429
US

V. Phone/Fax

Practice location:
  • Phone: 619-493-0541
  • Fax:
Mailing address:
  • Phone: 323-229-2185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: HELEN HAYES MOSESS
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 619-493-0541