Healthcare Provider Details

I. General information

NPI: 1780786566
Provider Name (Legal Business Name): DEENA ELIZABETH STAAB PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 FT STOCKTON ST
SAN DIEGO CA
92103
US

IV. Provider business mailing address

928 FT STOCKTON ST
SAN DIEGO CA
92103
US

V. Phone/Fax

Practice location:
  • Phone: 858-494-5025
  • Fax: 619-294-2929
Mailing address:
  • Phone: 858-494-5025
  • Fax: 619-294-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY12451
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: