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General NPI Number Information
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NPI Number | 1376224402
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Entity Type | Organization
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Legal Business Name | SOUL TIDE OUTPATIENT PSYCHOTHERAPY, PC
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Dates
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Enumeration Date | 07/31/2023
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Last Update Date | 02/03/2026
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Provider Practice Location Address
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Address Line | 3257 CAMINO DE LOS COCHES STE 303
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City | CARLSBAD
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State | CA
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Zip | 92009-8974
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Country | US
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Telephone | 858-945-7421
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Fax | 858-726-6265
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Provider Business Mailing Address
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Address Line | 2204 IRVING AVE
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City | SAN DIEGO
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State | CA
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Zip | 92113-2301
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Country | US
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Telephone | 858-945-7421
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Fax | 858-726-6265
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Authorized Official
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Title or Position | PSYCHOLOGIST/OWNER
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Name | TREVOR J OLSON
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Credential | PSYD
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Telephone | 855-945-7421
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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