=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356997761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN DIEGO DIVORCE COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2019
-----------------------------------------------------
Last Update Date | 08/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11622 EL CAMINO REAL STE 100
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-2051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-865-3203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 4TH AVE STE 207
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-5716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-865-3203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ CLINICAL DIRECTOR
-----------------------------------------------------
Name | MS. LYNN WALDMAN FLAX
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 619-865-3203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------