Provider Demographics
NPI:1043415847
Name:SAN DIEGO MENTAL HEALTH ASSOCIATES MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:SAN DIEGO MENTAL HEALTH ASSOCIATES MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLENISE
Authorized Official - Middle Name:C
Authorized Official - Last Name:TRAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-291-4808
Mailing Address - Street 1:3914 THIRD AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3094
Mailing Address - Country:US
Mailing Address - Phone:619-291-4808
Mailing Address - Fax:619-291-4426
Practice Address - Street 1:3914 THIRD AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3094
Practice Address - Country:US
Practice Address - Phone:619-291-4808
Practice Address - Fax:619-291-4426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC256972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ72044ZMedicaid
CAZZZ72044ZMedicaid