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General NPI Number Information
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NPI Number | 1528856531
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Entity Type | Organization
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Legal Business Name | SOUL TIDE PSYCHOTHERAPY PC
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Dates
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Enumeration Date | 04/29/2025
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 3257 CAMINO DE LOS COCHES
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City | CARLSBAD
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State | CA
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Zip | 92009-8976
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Country | US
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Telephone | 858-945-7421
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Fax |
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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 |
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Authorized Official
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Title or Position | SECRETARY
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Name | TREVOR OLSON
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Credential | PSY.D.
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Telephone | 858-945-7421
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0004X
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Taxonomy Name | Health Psychologist
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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 | 103TP0814X
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Taxonomy Name | Psychoanalysis Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TR0400X
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Taxonomy Name | Rehabilitation Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103TA0700X
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Taxonomy Name | Adult Development & Aging Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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