=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861523003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN DIEGO COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 08/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3177 OCEAN VIEW BLVD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92113-1432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-987-2797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8690 AERO DR SUITE 115-41
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-987-2797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SUPERVISOR
-----------------------------------------------------
Name | ANNE FITZGERALD
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 619-595-4418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 48542
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------