=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356204663
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA COPPOLA PHD
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2025
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1106 2ND ST STE 103 #535
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-5034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-814-1008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106 2ND ST STE 103 #535
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-5034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 36043
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------