Healthcare Provider Details

I. General information

NPI: 1457986226
Provider Name (Legal Business Name): PAUL RUSSELL OSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 10/25/2024
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4065 3RD AVE STE 223
SAN DIEGO CA
92103-2184
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2446
  • Fax: 619-269-0674
Mailing address:
  • Phone: 619-515-2300
  • Fax: 619-269-0674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC12712
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number101075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: