Provider Demographics
NPI:1629108188
Name:RENE, RACHELLE (PHD, BCB, HSM)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:RENE
Suffix:
Gender:F
Credentials:PHD, BCB, HSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 16259
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92176
Mailing Address - Country:US
Mailing Address - Phone:858-412-9660
Mailing Address - Fax:
Practice Address - Street 1:4656 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-3247
Practice Address - Country:US
Practice Address - Phone:858-412-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY23993103TC0700X, 103TP2701X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth