Healthcare Provider Details

I. General information

NPI: 1790980829
Provider Name (Legal Business Name): ROBERT MITCHELL AWALT PSY.D. AND LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 KENYON ST
SAN DIEGO CA
92110-5001
US

IV. Provider business mailing address

3437 UTAH ST
SAN DIEGO CA
92104-4109
US

V. Phone/Fax

Practice location:
  • Phone: 619-221-6550
  • Fax: 619-221-6556
Mailing address:
  • Phone: 619-221-6589
  • Fax: 619-221-6556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY16566
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY16566
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY16566
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY16566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: