=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003020231
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BORROWED STAR PSYCHOLOGY GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 01/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1294 W 6TH ST SUITE 105
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-902-6089
-----------------------------------------------------
Fax | 310-988-2883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1294 W 6TH ST SUITE 105
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-902-6089
-----------------------------------------------------
Fax | 310-988-2883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MELISSA ARIZPE
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 310-902-6089
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY17402
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------