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General NPI Number Information
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NPI Number | 1427415967
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE MIND & BODY PSYCHOTHERAPY, INC.
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Dates
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Enumeration Date | 01/27/2016
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Last Update Date | 01/27/2016
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Provider Practice Location Address
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Address Line | 2305 HISTORIC DECATUR RD STE 100
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City | SAN DIEGO
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State | CA
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Zip | 92106-6071
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Country | US
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Telephone | 619-354-2682
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Fax | 619-839-3780
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Provider Business Mailing Address
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Address Line | 2305 HISTORIC DECATUR RD STE 100
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City | SAN DIEGO
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State | CA
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Zip | 92106-6071
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Country | US
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Telephone | 619-354-2682
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Fax | 619-839-3780
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST
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Name | JODI L CEBALLOS
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Credential | PSY.D.
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Telephone | 619-354-2682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY26623
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License Number State | CA
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