Basic Information
| Provider Information | |||||||||
| NPI: | 1750458485 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADY CHILDREN'S HOSPITAL SAN DIEGO | ||||||||
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| OtherOrganizationName: | DEVELOPMENTAL EVALUATION CLINCI | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | MC5023 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665817 | ||||||||
| FaxNumber: | 8589668528 | ||||||||
| Practice Location | |||||||||
| Address1: | 8010 FROST ST. | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665817 | ||||||||
| FaxNumber: | 8589668528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 06/03/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR DEV SRVS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8589665416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 282NC2000X | PSY11584 | CA | N | Hospitals | General Acute Care Hospital | Children | 282NC2000X | 080000028 | CA | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.