Basic Information
| Provider Information | |||||||||
| NPI: | 1932223500 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADY CHILDREN'S HOSPITAL OUTPATIENT PSYCHIATRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 W CITRACADO PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920256479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602949270 | ||||||||
| FaxNumber: | 7602949268 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 W CITRACADO PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920256479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602949270 | ||||||||
| FaxNumber: | 7602949268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAZLEWOOD | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SITE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8584879050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | MFC 31074 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.