Provider Demographics
NPI:1649563065
Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Entity Type:Organization
Organization Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Other - Org Name:DEVELOPMENTAL EVALUATION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:DILLON
Authorized Official - Last Name:BIAL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:858-576-1700
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:MC 5023
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-1700
Mailing Address - Fax:858-966-7803
Practice Address - Street 1:11752 EL CAMINO REAL
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2050
Practice Address - Country:US
Practice Address - Phone:858-793-9591
Practice Address - Fax:858-793-0431
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADY CHILDREN'S HOSPITAL-SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X, 282N00000X
CA080000028282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty