MEDICARE: INTEGRATIVE PSYCHOLOGICAL SERVICES

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	21146	CA

General Provider Information

NPI Number	:	1164755526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	4565 RUFFNER ST STE 108
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2258
Country	:	US
Telephone Number	:	858-384-5891
Fax Number	:

Provider Business Practice Location Address
First Line	:	4565 RUFFNER ST STE 108
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2258
Country	:	US
Telephone Number	:	858-384-5891
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. YARON PRUGININ
Credential	:	PSY.D.
Telephone Number	:	858-384-5891

Provider Enumeration Date	:	09/16/2009
Last Update Date	:	09/16/2009

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