=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376184465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIC VAN DER VOORT PSYCHOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2019
-----------------------------------------------------
Last Update Date | 02/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 UNIVERSITY AVE STE E107-77
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-786-8685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 UNIVERSITY AVE STE E107-77
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-786-8685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ERIC WILLIAM VAN DER VOORT
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 619-786-8685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------