1376224402 NPI number — SOUL TIDE OUTPATIENT PSYCHOTHERAPY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376224402 NPI number — SOUL TIDE OUTPATIENT PSYCHOTHERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUL TIDE OUTPATIENT PSYCHOTHERAPY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376224402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2204 IRVING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92113-2301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-945-7421
Provider Business Mailing Address Fax Number:
858-726-6265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3257 CAMINO DE LOS COCHES STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92009-8974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-945-7421
Provider Business Practice Location Address Fax Number:
858-726-6265
Provider Enumeration Date:
07/31/2023

Additional Information

Authorized Official

Authorized Official Last Name:
OLSON
Authorized Official First Name:
TREVOR
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PSYCHOLOGIST/OWNER
Authorized Official Telephone Number:
855-945-7421

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2026 www.npivalidator.com