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SOUL TIDE PSYCHOTHERAPY
Complete NPI Record 1528856531
Psychologist - Clinical in San Diego, CA

NPI Status: Active since April 29, 2025

Contact Information

742 SANTA RITA PL
SAN DIEGO, CA
ZIP 92109
Phone: (858) 945-7421

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider First Line Business Mailing Address
  6. Provider Business Mailing Address City Name
  7. Provider Business Mailing Address State Name
  8. Provider Business Mailing Address Postal Code
  9. Provider Business Mailing Address Country Code If outside U S
  10. Provider Business Mailing Address Telephone Number
  11. Provider First Line Business Practice Location Address
  12. Provider Business Practice Location Address City Name
  13. Provider Business Practice Location Address State Name
  14. Provider Business Practice Location Address Postal Code
  15. Provider Business Practice Location Address Country Code If outside U S
  16. Provider Business Practice Location Address Telephone Number
  17. Provider Enumeration Date
  18. Last Update Date
  19. Authorized Official Last Name
  20. Authorized Official First Name
  21. Authorized Official Title or Position
  22. Authorized Official Telephone Number
  23. Healthcare Provider Taxonomy Code 1
  24. Healthcare Provider Primary Taxonomy Switch 1
  25. Healthcare Provider Taxonomy Code 2
  26. Healthcare Provider Primary Taxonomy Switch 2
  27. Healthcare Provider Taxonomy Code 3
  28. Healthcare Provider Primary Taxonomy Switch 3
  29. Healthcare Provider Taxonomy Code 4
  30. Healthcare Provider Primary Taxonomy Switch 4
  31. Healthcare Provider Taxonomy Code 5
  32. Healthcare Provider Primary Taxonomy Switch 5
  33. Healthcare Provider Taxonomy Code 6
  34. Healthcare Provider Primary Taxonomy Switch 6
  35. Healthcare Provider Taxonomy Code 7
  36. Healthcare Provider Primary Taxonomy Switch 7
  37. Healthcare Provider Taxonomy Code 8
  38. Healthcare Provider Primary Taxonomy Switch 8
  39. Healthcare Provider Taxonomy Code 9
  40. Healthcare Provider Primary Taxonomy Switch 9
  41. Healthcare Provider Taxonomy Code 10
  42. Healthcare Provider Primary Taxonomy Switch 10
  43. Is Organization Subpart
  44. Authorized Official Credential Text
  45. Healthcare Provider Taxonomy Group 1
  46. Healthcare Provider Taxonomy Group 2
  47. Healthcare Provider Taxonomy Group 3
  48. Healthcare Provider Taxonomy Group 4
  49. Healthcare Provider Taxonomy Group 5
  50. Healthcare Provider Taxonomy Group 6
  51. Healthcare Provider Taxonomy Group 7
  52. Healthcare Provider Taxonomy Group 8
  53. Healthcare Provider Taxonomy Group 9
  54. Healthcare Provider Taxonomy Group 10
  55. NPI Certification Date

Complete NPI Dataset

This page represents the complete record for NPI 1528856531. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1528856531
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: UNAVAIL
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address: 742 SANTA RITA PL
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City Name: SAN DIEGO
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: CA
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code: 921095046
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S : US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address Telephone Number: 8589457421
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider First Line Business Practice Location Address: 742 SANTA RITA PL
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: SAN DIEGO
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: CA
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 921095046
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 8589457421
The telephone number associated with the location address of the provider being identified.
Provider Enumeration Date: 4/29/2025
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 4/29/2025
The date that a record was last updated or changed.
Authorized Official Last Name: OLSON
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: TREVOR
The first name of the authorized official.
Authorized Official Title or Position: SECRETARY
The title or position of the authorized official.
Authorized Official Telephone Number: 8589457421
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 103TA0400X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1: N
Healthcare Provider Taxonomy Code 2: 103TA0700X
Healthcare Provider Primary Taxonomy Switch 2: N
Healthcare Provider Taxonomy Code 3: 103TB0200X
Healthcare Provider Primary Taxonomy Switch 3: N
Healthcare Provider Taxonomy Code 4: 103TC1900X
Healthcare Provider Primary Taxonomy Switch 4: N
Healthcare Provider Taxonomy Code 5: 103TC2200X
Healthcare Provider Primary Taxonomy Switch 5: N
Healthcare Provider Taxonomy Code 6: 103TF0000X
Healthcare Provider Primary Taxonomy Switch 6: N
Healthcare Provider Taxonomy Code 7: 103TH0004X
Healthcare Provider Primary Taxonomy Switch 7: N
Healthcare Provider Taxonomy Code 8: 103TP0814X
Healthcare Provider Primary Taxonomy Switch 8: N
Healthcare Provider Taxonomy Code 9: 103TR0400X
Healthcare Provider Primary Taxonomy Switch 9: N
Healthcare Provider Taxonomy Code 10: 103TC0700X
Healthcare Provider Primary Taxonomy Switch 10: Y
Is Organization Subpart: N
Authorized Official Credential Text: PSY.D.
Healthcare Provider Taxonomy Group 1: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 2: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 3: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 4: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 5: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 6: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 7: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 8: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 9: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 10: 193200000X MULTI-SPECIALTY GROUP
NPI Certification Date: 4/29/2025