MEDICARE: TALK THERAPY PSYCHOLOGY CENTER, CORP.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1013368141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALK THERAPY PSYCHOLOGY CENTER, CORP.

Provider Business Mailing Address
First Line	:	5935 CORNERSTONE CT W
Second Line	:	SUITE 125
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3737
Country	:	US
Telephone Number	:	858-205-2490
Fax Number	:

Provider Business Practice Location Address
First Line	:	5935 CORNERSTONE CT W
Second Line	:	SUITE 125
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3737
Country	:	US
Telephone Number	:	858-205-2490
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SEDA GRAGOSSIAN
Credential	:	PH.D.
Telephone Number	:	858-205-2490

Provider Enumeration Date	:	06/30/2016
Last Update Date	:	09/08/2016

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