Basic Information
| Provider Information | |||||||||
| NPI: | 1649563065 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADY CHILDREN'S HOSPITAL - SAN DIEGO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DEVELOPMENTAL EVALUATION CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | MC 5023 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589661700 | ||||||||
| FaxNumber: | 8589667803 | ||||||||
| Practice Location | |||||||||
| Address1: | 11752 EL CAMINO REAL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921302050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587939591 | ||||||||
| FaxNumber: | 8587930431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIAL | ||||||||
| AuthorizedOfficialFirstName: | VIRGINIA | ||||||||
| AuthorizedOfficialMiddleName: | DILLON | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8585761700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADY CHILDREN'S HOSPITAL-SAN DIEGO | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 282N00000X | 080000028 | CA | N | Hospitals | General Acute Care Hospital | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.