Provider Demographics
NPI:1588406177
Name:NEUROEVOLVE INTEGRATIVE HEALTH, A PROFESSIONAL PSYCHOLOGY CORPORATION
Entity type:Organization
Organization Name:NEUROEVOLVE INTEGRATIVE HEALTH, A PROFESSIONAL PSYCHOLOGY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCSW
Authorized Official - Phone:760-616-9311
Mailing Address - Street 1:10085 CARROLL CANYON RD STE 200H
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1100
Mailing Address - Country:US
Mailing Address - Phone:858-208-3463
Mailing Address - Fax:
Practice Address - Street 1:10085 CARROLL CANYON RD STE 200H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1100
Practice Address - Country:US
Practice Address - Phone:858-208-3463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-12
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty