Healthcare Provider Details

I. General information

NPI: 1700901774
Provider Name (Legal Business Name): MS. MARY ANN TASSONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6244 EL CAJON BLVD SUITE 15
SAN DIEGO CA
92115
US

IV. Provider business mailing address

5583 MICHAEL ST
SAN DIEGO CA
92105-3844
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-8225
  • Fax: 619-287-4146
Mailing address:
  • Phone: 619-733-2374
  • Fax: 619-741-2682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: