=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356496343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL PROFESSIONALS INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5190 GOVERNOR DR SUITE 101
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92122-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-558-3036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5190 GOVERNOR DR SUITE 101
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92122-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-558-3036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN J PERNA
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 858-558-3036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY5069
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------