Healthcare Provider Details

I. General information

NPI: 1952714321
Provider Name (Legal Business Name): INSTITUTE OF MODERN RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 CONGRESS ST SUITE 1D
SAN DIEGO CA
92110-2757
US

IV. Provider business mailing address

2725 CONGRESS ST SUITE 1D
SAN DIEGO CA
92110-2757
US

V. Phone/Fax

Practice location:
  • Phone: 619-288-6866
  • Fax:
Mailing address:
  • Phone: 619-288-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number51024
License Number StateCA

VIII. Authorized Official

Name: MR. CRESTON DAVIS
Title or Position: CEO-LMFT
Credential: MA
Phone: 619-288-6866