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General NPI Number Information
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NPI Number | 1215165253
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Entity Type | Organization
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Legal Business Name | EATING DISORDER CENTER OF SAN DIEGO
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Dates
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Enumeration Date | 06/29/2009
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Last Update Date | 06/29/2009
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Provider Practice Location Address
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Address Line | 740 LOMAS SANTA FE DR SUITE 205
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City | SOLANA BEACH
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State | CA
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Zip | 92075-1495
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Country | US
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Telephone | 858-353-5378
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Fax | 858-876-1863
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Provider Business Mailing Address
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Address Line | 740 LOMAS SANTA FE DR SUITE 205
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City | SOLANA BEACH
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State | CA
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Zip | 92075-1495
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Country | US
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Telephone | 858-353-5378
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Fax | 858-876-1863
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | PAGE M LAUER
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Credential | MFT
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Telephone | 858-353-5378
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC 40096
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License Number State | CA
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