Provider Demographics
NPI:1225520885
Name:AVITA FAMILY THERAPY AND WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:AVITA FAMILY THERAPY AND WELLNESS CENTER, INC.
Other - Org Name:AVITA FAMILY THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF THERAPY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRAD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:858-361-9228
Mailing Address - Street 1:PO BOX 2498
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-1798
Mailing Address - Country:US
Mailing Address - Phone:858-361-9228
Mailing Address - Fax:858-367-8383
Practice Address - Street 1:9666 BUSINESSPARK AVE STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131
Practice Address - Country:US
Practice Address - Phone:858-367-0525
Practice Address - Fax:858-367-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health