1457588998 NPI number — MS. KATARINA RADISAVLJEVIC MANSIR PSY.D.

Table of content: MS. KATARINA RADISAVLJEVIC MANSIR PSY.D. (NPI 1457588998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457588998 NPI number — MS. KATARINA RADISAVLJEVIC MANSIR PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANSIR
Provider First Name:
KATARINA
Provider Middle Name:
RADISAVLJEVIC
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PSY.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:
1457588998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
197 WOODLAND PKWY
Provider Second Line Business Mailing Address:
SUITE 104 PMB274
Provider Business Mailing Address City Name:
SAN MARCOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92069-3020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-465-9195
Provider Business Mailing Address Fax Number:
858-430-5265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4370 LA JOLLA VILLAGE DR
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-1249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-465-9195
Provider Business Practice Location Address Fax Number:
858-430-5265
Provider Enumeration Date:
06/11/2009

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY25417 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CB235234 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".