=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558001206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIA PSYCHOLOGY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2022
-----------------------------------------------------
Last Update Date | 01/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2635 CAMINO DEL RIO S STE 302
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-900-9393
-----------------------------------------------------
Fax | 858-900-9393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2635 CAMINO DEL RIO S STE 302
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-900-9393
-----------------------------------------------------
Fax | 858-900-9393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | COURTNEY GIBOI
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 858-900-9393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------