Provider Demographics
NPI:1588175616
Name:THRIVE THERAPY STUDIO, A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:THRIVE THERAPY STUDIO, A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLLERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:858-342-1304
Mailing Address - Street 1:5230 CARROLL CANYON RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1779
Mailing Address - Country:US
Mailing Address - Phone:858-342-1304
Mailing Address - Fax:
Practice Address - Street 1:5230 CARROLL CANYON RD STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1779
Practice Address - Country:US
Practice Address - Phone:858-342-1304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25614103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty