MEDICARE: THERAPEUTIC CENTER FOR ANXIETY AND TRAUMA, INDIVIDUAL AND FAMILY THERA

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	106H00000X	Marriage & Family Therapist	MFC49250	CA

General Provider Information

NPI Number	:	1770990657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPEUTIC CENTER FOR ANXIETY AND TRAUMA, INDIVIDUAL AND FAMILY THERA

Provider Business Mailing Address
First Line	:	2121 5TH AVE STE 214
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2139
Country	:	US
Telephone Number	:	619-272-6858
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 5TH AVE STE 214
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2139
Country	:	US
Telephone Number	:	619-272-6858
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	JENNIFER COSTANZA
Credential	:	LMFT
Telephone Number	:	619-272-6858

Provider Enumeration Date	:	07/12/2014
Last Update Date	:	08/19/2024

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