MEDICARE: CULTURAL PSYCHOLOGY CENTER

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	251V00000X	Voluntary or Charitable Agency	C3554466	CA

General Provider Information

NPI Number	:	1669867677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CULTURAL PSYCHOLOGY CENTER

Provider Business Mailing Address
First Line	:	6136 MISSION GORGE RD
Second Line	:	STE 129
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3494
Country	:	US
Telephone Number	:	619-282-4270
Fax Number	:

Provider Business Practice Location Address
First Line	:	6136 MISSION GORGE RD
Second Line	:	STE 129
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3494
Country	:	US
Telephone Number	:	619-282-4270
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER AND EXECUTIVE DIRECTOR
Name	:	SONIA INES CARBONELL
Credential	:	PSYD
Telephone Number	:	619-282-4270

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	04/06/2015

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