Provider Demographics
NPI:1033493598
Name:PERIVOLIOTIS, DIMITRI GEORGE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRI
Middle Name:GEORGE
Last Name:PERIVOLIOTIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 LA JOLLA VILLAGE DR
Mailing Address - Street 2:9116B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0002
Mailing Address - Country:US
Mailing Address - Phone:858-552-8585
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:9116B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017075103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical