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General NPI Number Information
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NPI Number | 1285362772
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Entity Type | Organization
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Legal Business Name | RENOVA SAN DIEGO
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Dates
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Enumeration Date | 08/11/2022
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Last Update Date | 08/11/2022
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Provider Practice Location Address
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Address Line | 12396 WORLD TRADE DR STE 109
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City | SAN DIEGO
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State | CA
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Zip | 92128-3787
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Country | US
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Telephone | 619-895-0509
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Fax |
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Provider Business Mailing Address
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Address Line | 12396 WORLD TRADE DR STE 109
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City | SAN DIEGO
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State | CA
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Zip | 92128-3787
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | HEATHER PEDERSON
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Credential |
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Telephone | 858-522-0179
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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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