Healthcare Provider Details

I. General information

NPI: 1124849658
Provider Name (Legal Business Name): SAN DIEGO STATE UNIVERSITY - HEALTHY EARLY YEARS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4283 EL CAJON BLVD SUITE 200
SAN DIEGO CA
92105
US

IV. Provider business mailing address

5500 CAMPANILE DR
SAN DIEGO CA
92182-1518
US

V. Phone/Fax

Practice location:
  • Phone: 619-530-0122
  • Fax: 619-530-0822
Mailing address:
  • Phone: 619-594-6017
  • Fax: 619-594-5917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: AGNES WONG NICKERSON
Title or Position: ASSOCIATE VP OF FINANCIAL OPERATION
Credential:
Phone: 619-594-6017