Healthcare Provider Details

I. General information

NPI: 1982366605
Provider Name (Legal Business Name): UC TELEHEALTH COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 10/11/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6363 GREENWICH DR
SAN DIEGO CA
92122-5947
US

IV. Provider business mailing address

6363 GREENWICH DR
SAN DIEGO CA
92122-5947
US

V. Phone/Fax

Practice location:
  • Phone: 918-809-2411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY VAN SLYKE
Title or Position: MANAGER, PROVIDER ENROLLMENT
Credential:
Phone: 918-809-2411