=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619178365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA MIDORI KAWAHARA PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10455 POMERADO RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92131-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-268-9054
-----------------------------------------------------
Fax | 858-635-4585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 74
-----------------------------------------------------
City | SAN LUIS REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92068-0074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-268-9054
-----------------------------------------------------
Fax | 858-635-4585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY15540
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------