Provider Demographics
NPI:1912365651
Name:STEPHANIE KNATZ PECK, PHD PSYCHOLOGICAL SERVICES INC
Entity Type:Organization
Organization Name:STEPHANIE KNATZ PECK, PHD PSYCHOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER,PSYCHOLOGIS
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNATZ PECK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:619-573-5073
Mailing Address - Street 1:4370 LA JOLLA VILLAGE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1251
Mailing Address - Country:US
Mailing Address - Phone:619-573-5073
Mailing Address - Fax:619-315-0448
Practice Address - Street 1:4370 LA JOLLA VILLAGE DR STE 400
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1251
Practice Address - Country:US
Practice Address - Phone:619-573-5073
Practice Address - Fax:619-315-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26162305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization