Healthcare Provider Details

I. General information

NPI: 1104160043
Provider Name (Legal Business Name): BASTYR UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 SORRENTO VALLEY BLVD
SAN DIEGO CA
92121-1407
US

IV. Provider business mailing address

4106 SORRENTO VALLEY BLVD
SAN DIEGO CA
92121-1407
US

V. Phone/Fax

Practice location:
  • Phone: 858-246-9730
  • Fax: 858-246-9710
Mailing address:
  • Phone: 858-246-9730
  • Fax: 858-246-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY11413
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND-556
License Number StateCA

VIII. Authorized Official

Name: MS. MOIRA PYLE FITZPATRICK
Title or Position: VICE PRESIDENT
Credential: PHD, ND
Phone: 858-246-9701