MEDICARE: MS. PATRICIA HERAS PH.D.

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	PSY 9788	CA

General Provider Information

NPI Number	:	1639238876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PATRICIA HERAS PH.D.

Provider Business Mailing Address
First Line	:	5665 OBERLIN DR STE 201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1739
Country	:	US
Telephone Number	:	858-453-9312
Fax Number	:	858-453-9314

Provider Business Practice Location Address
First Line	:	5665 OBERLIN DR STE 201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1739
Country	:	US
Telephone Number	:	858-453-9312
Fax Number	:	858-453-9314

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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