=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598161325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORENCE GRIFFITH JOYNER YOUTH FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2014
-----------------------------------------------------
Last Update Date | 11/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3093 CENTRAL AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92105-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-284-2443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3093 CENTRAL AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92105-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-284-2443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. ELIZABETH TATE
-----------------------------------------------------
Credential | MA, LMFT
-----------------------------------------------------
Telephone | 619-284-2443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LMFT83318
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------