Healthcare Provider Details

I. General information

NPI: 1336472869
Provider Name (Legal Business Name): NMCSD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

2435 ADAMS AVE #5
SAN DIEGO CA
92116-1343
US

V. Phone/Fax

Practice location:
  • Phone: 858-753-1735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number22507
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number22507
License Number StateCA

VIII. Authorized Official

Name: DR. ALEKSANDRA MARINOVIC
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 858-349-4496