Healthcare Provider Details

I. General information

NPI: 1932756152
Provider Name (Legal Business Name): BERTHA SANTILLAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 S MISSION RD STE 105
FALLBROOK CA
92028-3225
US

IV. Provider business mailing address

1119 S MISSION RD STE 105
FALLBROOK CA
92028-3225
US

V. Phone/Fax

Practice location:
  • Phone: 480-326-0775
  • Fax:
Mailing address:
  • Phone: 480-326-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW106250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: