=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558489591
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH HENRY BRATSKY PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 08/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3252 HOLIDAY CT STE 106
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-552-8181
-----------------------------------------------------
Fax | 858-552-0205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3252 HOLIDAY CT. #106
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-552-8181
-----------------------------------------------------
Fax | 858-552-0205
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | PSY7112
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------