=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548669286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENTAL HEALTH 365
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2014
-----------------------------------------------------
Last Update Date | 08/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4445 EASTGATE MALL SUITE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-724-7365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13272
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92039-3272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-724-7365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. EDWARD L DELALOZA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 844-724-7365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS21415
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------