Healthcare Provider Details

I. General information

NPI: 1578104113
Provider Name (Legal Business Name): WALTER ALEXANDER CICHOCKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 E GRAND AVE
ESCONDIDO CA
92025-4404
US

IV. Provider business mailing address

835 NORDAHL RD APT D
SAN MARCOS CA
92069-3555
US

V. Phone/Fax

Practice location:
  • Phone: 760-745-8478
  • Fax:
Mailing address:
  • Phone: 203-530-9243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: