=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689299455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRITON SUPPORT SERVICES, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2020
-----------------------------------------------------
Last Update Date | 06/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11770 BERNARDO PLAZA CT STE 116
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-2423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-251-0720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11770 BERNARDO PLAZA CT STE 116
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-2423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-405-0242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JESSICA ENGEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-405-0242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XF0002X
-----------------------------------------------------
Taxonomy Name | Feeding, Eating & Swallowing Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------