MEDICARE: WHOLE PERSON-PSYCHOTHERAPY INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1932764164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLE PERSON-PSYCHOTHERAPY INC.

Provider Business Mailing Address
First Line	:	9245 REGENTS RD UNIT M123
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-9258
Country	:	US
Telephone Number	:	858-353-8088
Fax Number	:	858-677-9037

Provider Business Practice Location Address
First Line	:	5230 CARROLL CANYON RD STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1779
Country	:	US
Telephone Number	:	858-353-8088
Fax Number	:	858-677-9037

Authorized Official
Title or Position	:	OWNER
Name	:	IREN FELLEGVARI
Credential	:	PSYD
Telephone Number	:	858-353-8088

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	05/02/2019

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