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General NPI Number Information
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NPI Number | 1154176295
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Entity Type | Organization
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Legal Business Name | RESTORE PSYCHOLOGY A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 04/22/2024
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Last Update Date | 02/16/2025
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Provider Practice Location Address
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Address Line | 5920 FRIARS RD STE 208
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City | SAN DIEGO
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State | CA
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Zip | 92108-1078
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Country | US
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Telephone | 337-517-7130
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Fax | 573-503-0122
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Provider Business Mailing Address
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Address Line | 5920 FRIARS RD STE 208
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City | SAN DIEGO
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State | CA
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Zip | 92108-1078
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Country | US
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Telephone | 337-517-7130
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Fax | 573-503-0122
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Authorized Official
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Title or Position | PRESIDENT
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Name | JACOB AMBROSE
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Credential | PHD
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Telephone | 337-517-7130
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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