=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003111501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARLSBAD RELATIONSHIP COUNSELING CENTER & PSYCHOTHERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2011
-----------------------------------------------------
Last Update Date | 02/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2774 JEFFERSON STREET
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-1769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-439-8874
-----------------------------------------------------
Fax | 760-729-7050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4725
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92052-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-439-8874
-----------------------------------------------------
Fax | 760-729-7050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE FAMILY THERAPIST OWNER
-----------------------------------------------------
Name | MRS. PATRICIA EILEEN VERNAZZA
-----------------------------------------------------
Credential | LMFT, ATR, BC
-----------------------------------------------------
Telephone | 760-439-8874
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 38682
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------