Provider Demographics
NPI:1255563433
Name:SIRIKANTRAPORN, SKULTIP (PSYD)
Entity type:Individual
Prefix:
First Name:SKULTIP
Middle Name:
Last Name:SIRIKANTRAPORN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5348 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-8025
Mailing Address - Country:US
Mailing Address - Phone:619-229-2999
Mailing Address - Fax:
Practice Address - Street 1:5348 UNIVERSITY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8025
Practice Address - Country:US
Practice Address - Phone:619-229-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA25612103TC0700X
NY019363103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program