Provider Demographics
NPI:1467737908
Name:PRINCE, RENEE KATHLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:KATHLEEN
Last Name:PRINCE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 WESTSIDE DR APT 314
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1233
Mailing Address - Country:US
Mailing Address - Phone:909-910-3781
Mailing Address - Fax:
Practice Address - Street 1:785 GRAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2370
Practice Address - Country:US
Practice Address - Phone:760-453-7175
Practice Address - Fax:760-453-7055
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32206103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical