Healthcare Provider Details

I. General information

NPI: 1003560632
Provider Name (Legal Business Name): CANVAS OF POSSIBILITIES PSYCHOLOGICAL SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 FIFTH AVE STE 230
SAN DIEGO CA
92103-5873
US

IV. Provider business mailing address

3033 FIFTH AVE STE 230
SAN DIEGO CA
92103-5873
US

V. Phone/Fax

Practice location:
  • Phone: 858-805-5302
  • Fax:
Mailing address:
  • Phone: 858-805-5302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIYA NIKOLAYEVNA KHOLODOVA
Title or Position: CEO
Credential: PH.D.
Phone: 858-805-5302