Provider Demographics
NPI:1477098242
Name:CHILD THERAPY SAN DIEGO
Entity Type:Organization
Organization Name:CHILD THERAPY SAN DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAPHAELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCCIA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:858-232-1836
Mailing Address - Street 1:1761 HOTEL CIR S STE 118
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3318
Mailing Address - Country:US
Mailing Address - Phone:858-232-1836
Mailing Address - Fax:
Practice Address - Street 1:1761 HOTEL CIR S STE 118
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3318
Practice Address - Country:US
Practice Address - Phone:858-232-1836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52988106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty