Healthcare Provider Details

I. General information

NPI: 1235770181
Provider Name (Legal Business Name): THE LOTUS COLLABORATIVE, INC., A PSYCHOLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 MISSION ST
SANTA CRUZ CA
95060-3612
US

IV. Provider business mailing address

611 MISSION ST
SANTA CRUZ CA
95060-3612
US

V. Phone/Fax

Practice location:
  • Phone: 831-600-7103
  • Fax:
Mailing address:
  • Phone: 831-600-7103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH PORTER
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 831-588-0497