Healthcare Provider Details

I. General information

NPI: 1356997761
Provider Name (Legal Business Name): SAN DIEGO DIVORCE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11622 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-2051
US

IV. Provider business mailing address

3200 4TH AVE STE 207
SAN DIEGO CA
92103-5716
US

V. Phone/Fax

Practice location:
  • Phone: 619-865-3203
  • Fax:
Mailing address:
  • Phone: 619-865-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNN WALDMAN FLAX
Title or Position: OWNER/ CLINICAL DIRECTOR
Credential: LCSW
Phone: 619-865-3203