Healthcare Provider Details

I. General information

NPI: 1720616600
Provider Name (Legal Business Name): CENTER FOR REFLECTIVE PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9606 TIERRA GRANDE ST STE 201
SAN DIEGO CA
92126-6501
US

IV. Provider business mailing address

PO BOX 421146
SAN DIEGO CA
92142-1146
US

V. Phone/Fax

Practice location:
  • Phone: 619-369-5050
  • Fax: 877-485-5961
Mailing address:
  • Phone: 619-369-5050
  • Fax: 877-485-5961

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 TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SHERRY CASPER
Title or Position: OWNER
Credential: PHD
Phone: 619-369-5050