Healthcare Provider Details

I. General information

NPI: 1407421001
Provider Name (Legal Business Name): EILEEN ZICCARDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 AVENIDA VAQUERO
SAN CLEMENTE CA
92673-2901
US

IV. Provider business mailing address

621 AVENIDA VAQUERO
SAN CLEMENTE CA
92673-2901
US

V. Phone/Fax

Practice location:
  • Phone: 520-686-1857
  • Fax:
Mailing address:
  • Phone: 520-686-1857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC9666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: