=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700453263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A SALTED LYFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2021
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 N EL CAMINO REAL STE 202
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-4778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-682-5521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 N EL CAMINO REAL STE 202
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-4778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-682-5521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LYSSA KERRIGAN
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 949-682-5521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------