Healthcare Provider Details

I. General information

NPI: 1194159871
Provider Name (Legal Business Name): TIAGO BARCELOS ANTONIO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8851 CENTER DR STE 312
LA MESA CA
91942-3050
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2383
  • Fax:
Mailing address:
  • Phone: 619-515-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number90529
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number90529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: