Healthcare Provider Details

I. General information

NPI: 1255325387
Provider Name (Legal Business Name): KAYE PESAVENTO LCSW,BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 OTAY LAKES RD SUITE 107
BONITA CA
91902-2443
US

IV. Provider business mailing address

682 RUE AVALLON
CHULA VISTA CA
91913-1212
US

V. Phone/Fax

Practice location:
  • Phone: 619-227-5079
  • Fax: 619-656-0835
Mailing address:
  • Phone: 619-227-5079
  • Fax: 619-656-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 5694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: