=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437398468
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES A. REAVIS, PSY.D. A PSYCHOLOGICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2009
-----------------------------------------------------
Last Update Date | 02/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 964 5TH AVE # 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92101-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-234-7970
-----------------------------------------------------
Fax | 619-699-5945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 964 5TH AVE # 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92101-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-234-7970
-----------------------------------------------------
Fax | 619-699-5945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JAMES A REAVIS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 619-234-7970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | PSY17404
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------