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NPI Code Detail

MEDICARE: PACIFIC NEUROBEHAVIORAL CLINIC: A PSYCHOLOGICAL CORPORATION

MEDICARE: PACIFIC NEUROBEHAVIORAL CLINIC: A PSYCHOLOGICAL CORPORATION
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
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)
2103T00000XPsychologist
3103G00000XClinical Neuropsychologist
4251S00000XCommunity/Behavioral Health AgencyPSY22738CA

General Provider Information

NPI Number : 1952724817
Entity Type Code : Organization
Provider Name (Legal Business Name) : PACIFIC NEUROBEHAVIORAL CLINIC: A PSYCHOLOGICAL CORPORATION
Provider Business Mailing Address
First Line : 3990 OLD TOWN AVE STE C303
Second Line :
City : SAN DIEGO
State : CA
Zip : 92110-2932
Country : US
Telephone Number : 858-964-0722
Fax Number : 866-437-0375
Provider Business Practice Location Address
First Line : 3990 OLD TOWN AVE STE C303
Second Line :
City : SAN DIEGO
State : CA
Zip : 92110-2932
Country : US
Telephone Number : 858-964-0722
Fax Number : 866-437-0375
Authorized Official
Title or Position : CEO
Name : ALEXIS OLSON BACHIEGA
Credential : PHD
Telephone Number : 858-964-0722
Provider Enumeration Date : 01/29/2014
Last Update Date : 05/26/2026

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