Healthcare Provider Details

I. General information

NPI: 1285362772
Provider Name (Legal Business Name): RENOVA SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12396 WORLD TRADE DR STE 109
SAN DIEGO CA
92128-3787
US

IV. Provider business mailing address

12396 WORLD TRADE DR STE 109
SAN DIEGO CA
92128-3787
US

V. Phone/Fax

Practice location:
  • Phone: 619-895-0509
  • Fax:
Mailing address:
  • Phone: 858-722-4372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCHITA MASTERS
Title or Position: DIRECTOR OF CLINICAL PSYCH PROGRAM
Credential: PSY.D.
Phone: 858-722-4372