Provider Demographics
NPI:1235639733
Name:SAN DIEGO THERAPY GROUP, A PROFESSIONAL PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:SAN DIEGO THERAPY GROUP, A PROFESSIONAL PSYCHOLOGY CORPORATION
Other - Org Name:SAN DIEGO THERAPY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:619-800-0821
Mailing Address - Street 1:3760 CONVOY ST.
Mailing Address - Street 2:STE. 118
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111
Mailing Address - Country:US
Mailing Address - Phone:619-800-0821
Mailing Address - Fax:858-292-0143
Practice Address - Street 1:3760 CONVOY ST.
Practice Address - Street 2:STE. 118
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111
Practice Address - Country:US
Practice Address - Phone:619-800-0821
Practice Address - Fax:858-292-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-20
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA24952103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty