Healthcare Provider Details

I. General information

NPI: 1356011217
Provider Name (Legal Business Name): PACIFIC INTEGRATIVE THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HIGH BLUFF DR STE 103
SAN DIEGO CA
92130-2053
US

IV. Provider business mailing address

12636 HIGH BLUFF DR
SAN DIEGO CA
92130-2022
US

V. Phone/Fax

Practice location:
  • Phone: 858-877-1750
  • Fax: 855-554-1110
Mailing address:
  • Phone: 858-877-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. HEDIEH AZADMEHR
Title or Position: PRESIDENT
Credential: PH.D
Phone: 858-877-1750