MEDICARE: DR. LAURA WEISS

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	103T00000X	Psychologist	PSY21254	CA

General Provider Information

NPI Number	:	1902057789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA WEISS

Provider Business Mailing Address
First Line	:	110 W PENNSYLVANIA AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4016
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 W PENNSYLVANIA AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4016
Country	:	US
Telephone Number	:	619-342-1412
Fax Number	:

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

Provider Enumeration Date	:	10/10/2008
Last Update Date	:	10/10/2008

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