Healthcare Provider Details

I. General information

NPI: 1912820192
Provider Name (Legal Business Name): CAROLINA CERVANTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 F STREET UNIT 100
CHULA VISTA CA
91910
US

IV. Provider business mailing address

5075 SHOREHAM PL STE 115
SAN DIEGO CA
92122-5927
US

V. Phone/Fax

Practice location:
  • Phone: 858-272-2662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: