Healthcare Provider Details

I. General information

NPI: 1972421824
Provider Name (Legal Business Name): SAN DIEGO MOUNTAIN 2 COAST THERAPY, PROFESSIONAL CLINICAL COUNSELOR CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 HIGHWAY 79
JULIAN CA
92036
US

IV. Provider business mailing address

PO BOX 191
SANTA YSABEL CA
92070-0191
US

V. Phone/Fax

Practice location:
  • Phone: 760-420-6501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANGELINE BAUCOM
Title or Position: OWNER
Credential: LPCC
Phone: 760-420-6501