Provider Demographics
NPI:1013362615
Name:RESTORATION THERAPY CENTER OF SD, A MFT CORP
Entity Type:Organization
Organization Name:RESTORATION THERAPY CENTER OF SD, A MFT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ELVIN
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:AHL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MDIV
Authorized Official - Phone:714-222-0331
Mailing Address - Street 1:5650 EL CAMINO REAL
Mailing Address - Street 2:STE 130
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-7124
Mailing Address - Country:US
Mailing Address - Phone:714-222-0331
Mailing Address - Fax:
Practice Address - Street 1:5650 EL CAMINO REAL
Practice Address - Street 2:STE 130
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7124
Practice Address - Country:US
Practice Address - Phone:714-222-0331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#86028106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty