Healthcare Provider Details

I. General information

NPI: 1700409760
Provider Name (Legal Business Name): PEARL BASALDUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4685 3RD ST.
LA MESA CA
91941
US

IV. Provider business mailing address

4685 3RD ST
LA MESA CA
91941-5529
US

V. Phone/Fax

Practice location:
  • Phone: 831-295-4456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC20919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: