Healthcare Provider Details

I. General information

NPI: 1255941027
Provider Name (Legal Business Name): SOLEDAD GONZALEZSEVILLA ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 11/16/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 N GRAPE ST
ESCONDIDO CA
92025-3079
US

IV. Provider business mailing address

490 N GRAPE ST
ESCONDIDO CA
92025-3079
US

V. Phone/Fax

Practice location:
  • Phone: 760-975-9939
  • Fax:
Mailing address:
  • Phone: 760-975-9939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number109418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: