MEDICARE: RADY'S CHILDREN'S HOSPITAL OUTPATIENT PSYCHIATRY SAN DIEGO

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	106H00000X	Marriage & Family Therapist	IMF 47771	CA

General Provider Information

NPI Number	:	1962508481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADY'S CHILDREN'S HOSPITAL OUTPATIENT PSYCHIATRY SAN DIEGO

Provider Business Mailing Address
First Line	:	1465 C ST
Second Line	:	#3305
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-5738
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3665 KEARNY VILLA RD
Second Line	:	165
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1953
Country	:	US
Telephone Number	:	619-758-5993
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER I
Name	:	MERAV SEGALL
Credential	:	MA
Telephone Number	:	619-758-5993

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	06/23/2008

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