=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679031736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY SYSTEMS AND CHILD THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2019
-----------------------------------------------------
Last Update Date | 03/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2878 CAMINO DEL RIO S STE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-784-6793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2878 CAMINO DEL RIO S STE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-784-6793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | THI WLODARSKI
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 619-784-6703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------