Provider Demographics
NPI:1801172879
Name:SAGE DE BEIXEDON BRESLIN, PH.D.: PSYCHOLOGIST - A PROFESSIONAL CORP
Entity type:Organization
Organization Name:SAGE DE BEIXEDON BRESLIN, PH.D.: PSYCHOLOGIST - A PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, CFO / LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAGE
Authorized Official - Middle Name:DE BEIXEDON
Authorized Official - Last Name:BRESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-481-8810
Mailing Address - Street 1:990 HIGHLAND DR
Mailing Address - Street 2:SUITE100
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2408
Mailing Address - Country:US
Mailing Address - Phone:858-481-8810
Mailing Address - Fax:858-481-8816
Practice Address - Street 1:990 HIGHLAND DR
Practice Address - Street 2:SUITE100
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2408
Practice Address - Country:US
Practice Address - Phone:858-481-8810
Practice Address - Fax:858-481-8816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14131103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty