Healthcare Provider Details

I. General information

NPI: 1588929772
Provider Name (Legal Business Name): GERY LIWERANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N JOHNSON AVE STE 101
EL CAJON CA
92020-1651
US

IV. Provider business mailing address

4275 MARS WAY
LA MESA CA
91941-7281
US

V. Phone/Fax

Practice location:
  • Phone: 619-442-0277
  • Fax: 619-442-1101
Mailing address:
  • Phone: 619-793-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: