Provider Demographics
NPI:1588873848
Name:DUBENETZKY, SALOME KHALILI (PSYD)
Entity type:Individual
Prefix:DR
First Name:SALOME
Middle Name:KHALILI
Last Name:DUBENETZKY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:SALOME
Other - Middle Name:KHALILI
Other - Last Name:YEKTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 270324
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-2324
Mailing Address - Country:US
Mailing Address - Phone:619-405-7284
Mailing Address - Fax:
Practice Address - Street 1:4000 MACARTHUR BLVD STE 600
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2517
Practice Address - Country:US
Practice Address - Phone:949-432-9173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32732103TC0700X
101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist