Healthcare Provider Details

I. General information

NPI: 1437980026
Provider Name (Legal Business Name): WAVE ACADEMY DBA HEALING WAVE AQUATICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2657 ARIANE DR
SAN DIEGO CA
92117-3422
US

IV. Provider business mailing address

2657 ARIANE DR
SAN DIEGO CA
92117-3422
US

V. Phone/Fax

Practice location:
  • Phone: 619-453-0953
  • Fax:
Mailing address:
  • Phone: 619-453-0953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH BERG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 619-453-0953