Provider Demographics
NPI:1093865073
Name:SCOORTIS, PHAEDRA NICOLE (MA, MFT)
Entity Type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:NICOLE
Last Name:SCOORTIS
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2604
Mailing Address - Country:US
Mailing Address - Phone:619-972-0209
Mailing Address - Fax:
Practice Address - Street 1:2727 CAMINO DEL RIO SOUTH, SUITE 311
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:619-972-0209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43174106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist