Provider Demographics
NPI:1356997761
Name:SAN DIEGO DIVORCE COUNSELING CENTER
Entity type:Organization
Organization Name:SAN DIEGO DIVORCE COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:WALDMAN
Authorized Official - Last Name:FLAX
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:619-865-3203
Mailing Address - Street 1:3200 4TH AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5716
Mailing Address - Country:US
Mailing Address - Phone:619-865-3203
Mailing Address - Fax:
Practice Address - Street 1:11622 EL CAMINO REAL STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2051
Practice Address - Country:US
Practice Address - Phone:619-865-3203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty