Basic Information
| Provider Information | |||||||||
| NPI: | 1811927106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4550 KEARNY VILLA RD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582791223 | ||||||||
| FaxNumber: | 8584677161 | ||||||||
| Practice Location | |||||||||
| Address1: | 4550 KEARNY VILLA RD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582791223 | ||||||||
| FaxNumber: | 8584677161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 05/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | GUTIERREZ | ||||||||
| AuthorizedOfficialFirstName: | ROSBEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8582791223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2462 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101YM0800X | 028385-06 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | W13604 | 01 | CA | MEDICARE | OTHER |