=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932838018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC BEHAVIORAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2022
-----------------------------------------------------
Last Update Date | 06/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3244 CAMINITO EASTBLUFF UNIT 44
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-2886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-280-9151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3244 CAMINITO EASTBLUFF UNIT 44
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-2886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-280-9151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JOSEPH PRINDLE
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 520-280-9151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------