=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467329631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOTIC MOOD & ANXIETY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2025
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4668 CORTE MAR DEL CORAZON
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-2692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-287-9630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11120 E OCEAN AIR DR STE B-101170
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-4683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-287-9630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHARMIN NABI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 562-287-9630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------