MEDICARE: SJC BEHAVIORAL HEALTH

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 24668	CA

General Provider Information

NPI Number	:	1851756001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SJC BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	2333 CAMINO DEL RIO S STE 160
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3617
Country	:	US
Telephone Number	:	619-342-4155
Fax Number	:

Provider Business Practice Location Address
First Line	:	2333 CAMINO DE RIO S
Second Line	:	160
City	:	SAN DIEGO
State	:	CA
Zip	:	92108
Country	:	US
Telephone Number	:	619-342-4155
Fax Number	:

Authorized Official
Title or Position	:	OWNER / CLINICAL PSYCHOLOGIST
Name	:	DR. STEVEN COVELLUZZI
Credential	:	PSY.D.
Telephone Number	:	619-342-4155

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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