=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992832109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL STANDAL PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 02/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4452 PARK BLVD 212
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92116-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-775-2501
-----------------------------------------------------
Fax | 619-684-5459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4452 PARK BLVD 212
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92116-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-775-2501
-----------------------------------------------------
Fax | 619-684-5459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY21606
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------