Provider Demographics
NPI:1083003586
Name:SAN DIEGO PSYCHOLOGICAL CENTER INC.
Entity Type:Organization
Organization Name:SAN DIEGO PSYCHOLOGICAL CENTER INC.
Other - Org Name:SDPC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BANAFSHEH
Authorized Official - Middle Name:
Authorized Official - Last Name:PEZESHK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:760-607-6463
Mailing Address - Street 1:2258 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-6613
Mailing Address - Country:US
Mailing Address - Phone:760-607-6463
Mailing Address - Fax:760-607-3433
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE B3
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:760-607-6463
Practice Address - Fax:760-607-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22844103T00000X
103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184959009OtherPERSONAL NPI