Provider Demographics
NPI:1932223500
Name:RADY CHILDREN'S HOSPITAL OUTPATIENT PSYCHIATRY
Entity Type:Organization
Organization Name:RADY CHILDREN'S HOSPITAL OUTPATIENT PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SITE COORDINATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZLEWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-487-9050
Mailing Address - Street 1:625 W CITRACADO PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-6479
Mailing Address - Country:US
Mailing Address - Phone:760-294-9270
Mailing Address - Fax:760-294-9268
Practice Address - Street 1:625 W CITRACADO PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-6479
Practice Address - Country:US
Practice Address - Phone:760-294-9270
Practice Address - Fax:760-294-9268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 31074261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health