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General NPI Number Information
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NPI Number | 1225520885
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Entity Type | Organization
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Legal Business Name | AVITA FAMILY THERAPY AND WELLNESS CENTER, INC.
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Dates
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Enumeration Date | 05/30/2018
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Last Update Date | 08/25/2018
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Provider Practice Location Address
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Address Line | 9666 BUSINESSPARK AVE STE 207
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City | SAN DIEGO
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State | CA
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Zip | 92131
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Country | US
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Telephone | 858-367-0525
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Fax | 858-367-8383
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Provider Business Mailing Address
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Address Line | PO BOX 2498
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City | DEL MAR
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State | CA
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Zip | 92014-1798
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Country | US
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Telephone | 858-361-9228
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Fax | 858-367-8383
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Authorized Official
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Title or Position | DIRECTOR OF THERAPY SERVICES
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Name | SARA HIRAD
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Credential | PSY.D.
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Telephone | 858-361-9228
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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