=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649934795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDSAY ELIZONDO PSYCHOLOGY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2021
-----------------------------------------------------
Last Update Date | 10/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 LAUREL ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92101-1630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-289-7597
-----------------------------------------------------
Fax | 619-354-7283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 LAUREL ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92101-1630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-289-7597
-----------------------------------------------------
Fax | 619-354-7283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. LINDSAY ELIZONDO
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 619-289-7597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------