Healthcare Provider Details

I. General information

NPI: 1053036509
Provider Name (Legal Business Name): IVAN ALEJANDRO MERCADO PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 CAMINO DEL RIO N STE 300
SAN DIEGO CA
92108-1746
US

IV. Provider business mailing address

3530 CAMINO DEL RIO N STE 300
SAN DIEGO CA
92108-1746
US

V. Phone/Fax

Practice location:
  • Phone: 619-282-8211
  • Fax: 619-282-1300
Mailing address:
  • Phone: 619-282-8211
  • Fax: 619-282-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: