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General NPI Number Information
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NPI Number | 1851731079
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Entity Type | Organization
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Legal Business Name | SAN DIEGO CENTER FOR NEUROFEEDBACK
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Dates
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Enumeration Date | 07/02/2013
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Last Update Date | 07/02/2013
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Provider Practice Location Address
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Address Line | 12064 WOODSIDE AVE STE 105
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City | LAKESIDE
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State | CA
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Zip | 92040-2951
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Country | US
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Telephone | 619-448-1216
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Fax |
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Provider Business Mailing Address
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Address Line | 12064 WOODSIDE AVE STE 105
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City | LAKESIDE
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State | CA
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Zip | 92040-2951
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Country | US
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Telephone | 619-448-1216
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHRISTIANA KATARINA SILVA
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Credential | PH.D.
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Telephone | 619-448-1216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY 21878
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License Number State | CA
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