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3636 4th Ave Ste 304 San Diego CA 92103-4294 | |
| (858) 342-0948 | |
| (858) 481-8281 |
| Full Name | |
|---|---|
| Speciality | Psychologist |
| Location | 3636 4th Ave Ste 304, San Diego, California |
| Authorized Official Name and Position | Annette Conway (PRESIDENT) |
| Authorized Official Contact | 8583420948 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
3636 4th Ave Ste 304 San Diego CA 92103-4294 Ph: (858) 342-0948 | 3636 4th Ave Ste 304 San Diego CA 92103-4294 Ph: (858) 342-0948 |
| NPI Number | 1083959092 |
|---|---|
| Provider Enumeration Date | 12/02/2012 |
| Last Update Date | 01/11/2023 |
| Certification Date | 01/11/2023 |
| Medicare PECOS PAC ID | 3274778188 |
|---|---|
| Medicare Enrollment ID | O20130326000089 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1083959092 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | PSY19997 (California) | Primary |
| Provider Name | Annette M Conway |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1003852120 PECOS PAC ID: 3678531092 Enrollment ID: I20041230000520 |
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