Healthcare Provider Details

I. General information

NPI: 1093430696
Provider Name (Legal Business Name): SHURENE LARAE PREMO ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BIRMINGHAM DR # 240A
CARDIFF CA
92007-1757
US

IV. Provider business mailing address

120 BIRMINGHAM DR # 240A
CARDIFF CA
92007-1757
US

V. Phone/Fax

Practice location:
  • Phone: 858-208-0121
  • Fax: 858-381-9768
Mailing address:
  • Phone: 858-208-0121
  • Fax: 858-381-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99213
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99213
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number99213
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: