MEDICARE: EL CAMINO PSYCHOLOGY SERVICES. PC

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	PSY10467	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932233178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EL CAMINO PSYCHOLOGY SERVICES. PC

Provider Business Mailing Address
First Line	:	2181 S EL CAMINO REAL STE 307
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6288
Country	:	US
Telephone Number	:	760-722-4233
Fax Number	:	760-722-4232

Provider Business Practice Location Address
First Line	:	2181 S EL CAMINO REAL STE 307
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6288
Country	:	US
Telephone Number	:	760-722-4233
Fax Number	:	760-722-4232

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. BROCK KENNETH KILBOURNE
Credential	:	PH.D.
Telephone Number	:	760-722-4233

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	10/20/2008

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