Provider Demographics
NPI:1962508481
Name:RADY'S CHILDREN'S HOSPITAL OUTPATIENT PSYCHIATRY SAN DIEGO
Entity Type:Organization
Organization Name:RADY'S CHILDREN'S HOSPITAL OUTPATIENT PSYCHIATRY SAN DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER I
Authorized Official - Prefix:
Authorized Official - First Name:MERAV
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:619-758-5993
Mailing Address - Street 1:1465 C ST
Mailing Address - Street 2:#3305
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3665 KEARNY VILLA RD
Practice Address - Street 2:165
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1953
Practice Address - Country:US
Practice Address - Phone:619-758-5993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 47771106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty