Healthcare Provider Details

I. General information

NPI: 1396450714
Provider Name (Legal Business Name): DEJSA EDWARDS SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date: 12/18/2023
Reactivation Date: 12/29/2023

III. Provider practice location address

9920 PACIFIC HEIGHTS BLVD SUITE 150
SAN DIEGO CA
92121-4396
US

IV. Provider business mailing address

1660 HOTEL CIR N STE 314
SAN DIEGO CA
92108-2803
US

V. Phone/Fax

Practice location:
  • Phone: 303-989-8169
  • Fax:
Mailing address:
  • Phone: 619-759-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19113
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: