MEDICARE: ASCENT 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	251S00000X	Community/Behavioral Health Agency
2	252Y00000X	Early Intervention Provider Agency
3	103TC0700X	Clinical Psychologist	26523	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1457760357	OTHER		NPI
2	1255879722	OTHER		NPI

General Provider Information

NPI Number	:	1700383825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASCENT PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	4652 BANNOCK AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-2922
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4652 BANNOCK AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-2922
Country	:	US
Telephone Number	:	614-323-2617
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LAUREN GASSIER
Credential	:
Telephone Number	:	614-323-2617

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	04/06/2018

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