Healthcare Provider Details

I. General information

NPI: 1760575963
Provider Name (Legal Business Name): RADY CHILDREN'S OUTPATIENT PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3559 INDIANA ST APT 8
SAN DIEGO CA
92103-5244
US

IV. Provider business mailing address

3559 INDIANA ST APT 8
SAN DIEGO CA
92103-5244
US

V. Phone/Fax

Practice location:
  • Phone: 619-851-4201
  • Fax:
Mailing address:
  • Phone: 619-851-4201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. LISA HAZLEWOOD
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D
Phone: 858-487-9050