1104949619 NPI number — DR. SALLY ANN SCHWERDTFEGER PH.D.

Table of content: DR. SALLY ANN SCHWERDTFEGER PH.D. (NPI 1104949619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104949619 NPI number — DR. SALLY ANN SCHWERDTFEGER PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHWERDTFEGER
Provider First Name:
SALLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

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:
1104949619
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1761 HOTEL CIRCLE S.
Provider Second Line Business Mailing Address:
STE 358
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-295-2600
Provider Business Mailing Address Fax Number:
619-295-9096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3368 2ND AVE
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-5666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-295-2600
Provider Business Practice Location Address Fax Number:
619-295-9096
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 8348 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TP0016X , with the licence number: PSY8348 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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