Provider Demographics
NPI:1043536998
Name:INTERNATIONAL CENTER FOR BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:INTERNATIONAL CENTER FOR BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DMITRIY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVTSOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-729-4770
Mailing Address - Street 1:4146 CAMINITO CASSIS
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3252 HOLIDAY CT
Practice Address - Street 2:STE 108
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0027
Practice Address - Country:US
Practice Address - Phone:858-729-4668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-18
Last Update Date:2010-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88348251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health