MEDICARE: WISE SELF PSYCHOLOGY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1003474180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE SELF PSYCHOLOGY, INC.

Provider Business Mailing Address
First Line	:	2535 KETTNER BLVD STE 2B1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1253
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2535 KETTNER BLVD STE 2B1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1253
Country	:	US
Telephone Number	:	619-678-0020
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. INGA CURRY
Credential	:	PHD
Telephone Number	:	619-678-0020

Provider Enumeration Date	:	06/03/2019
Last Update Date	:	06/11/2019

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