=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457542276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAYNA NELSON, PSYD FAMILY PSYCHOLOGY, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 01/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5805 CAPISTRANO AVE STE B
-----------------------------------------------------
City | ATASCADERO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93422-7218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-476-6420
-----------------------------------------------------
Fax | 866-476-6420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1589 GRANACHE WAY
-----------------------------------------------------
City | TEMPLETON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93465-3830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-476-6420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAYNA NELSON
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 866-476-6420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY18730
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------