Provider Demographics
NPI:1710305818
Name:DEBORAH COSMETIS, PSY.D., PSYCHOLOGIST INC.
Entity Type:Organization
Organization Name:DEBORAH COSMETIS, PSY.D., PSYCHOLOGIST INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:COSMETIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:619-786-0674
Mailing Address - Street 1:3990 OLD TOWN AVE STE A208
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2967
Mailing Address - Country:US
Mailing Address - Phone:619-786-0674
Mailing Address - Fax:
Practice Address - Street 1:3990 OLD TOWN AVE STE A208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2967
Practice Address - Country:US
Practice Address - Phone:619-786-0674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24117103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFO693AMedicare UPIN