Provider Demographics
NPI:1316417009
Name:SAN DIEGO PSYCHOLOGY & TELEHEALTH
Entity Type:Organization
Organization Name:SAN DIEGO PSYCHOLOGY & TELEHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LUKASZ
Authorized Official - Middle Name:
Authorized Official - Last Name:URBAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:619-314-5560
Mailing Address - Street 1:5252 BALBOA AVE STE 1004
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6986
Mailing Address - Country:US
Mailing Address - Phone:619-314-5560
Mailing Address - Fax:
Practice Address - Street 1:5252 BALBOA AVE STE 1004
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6986
Practice Address - Country:US
Practice Address - Phone:619-314-5560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health