Provider Demographics
NPI:1154176295
Name:RESTORE PSYCHOLOGY A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:RESTORE PSYCHOLOGY A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:337-517-7130
Mailing Address - Street 1:5920 FRIARS RD STE 208
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1078
Mailing Address - Country:US
Mailing Address - Phone:337-517-7130
Mailing Address - Fax:573-503-0122
Practice Address - Street 1:5920 FRIARS RD STE 208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1078
Practice Address - Country:US
Practice Address - Phone:337-517-7130
Practice Address - Fax:573-503-0122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-22
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty