MEDICARE: AMY M DRAHOTA PH.D.

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	25593	CA
2	103TB0200X	Cognitive & Behavioral Psychologist	25593	CA
3	103TC2200X	Clinical Child & Adolescent Psychologist	25593	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12553783	OTHER		CAQH PROVIDER ID
2	25593	OTHER	CA	CALIFORNIA BOARD OF PSYCHOLOGY LICENSE

General Provider Information

NPI Number	:	1952733529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY M DRAHOTA PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 261705
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92196-1705
Country	:	US
Telephone Number	:	858-966-7703
Fax Number	:	858-966-7704

Provider Business Practice Location Address
First Line	:	3020 CHILDREN'S WAY
Second Line	:	MC 5042
City	:	SAN DIEGO
State	:	CA
Zip	:	92123
Country	:	US
Telephone Number	:	858-966-7453
Fax Number	:	858-966-8011

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

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	08/06/2013

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