=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104051804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACH PSYCHOTHERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2009
-----------------------------------------------------
Last Update Date | 05/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1767 GRAND AVE STE 4
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-293-8123
-----------------------------------------------------
Fax | 858-273-9410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1767 GRAND AVE STE 4
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-293-8123
-----------------------------------------------------
Fax | 858-273-9410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-DIRECTOR
-----------------------------------------------------
Name | NICOLE DOCKTER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 619-318-5012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------