Healthcare Provider Details

I. General information

NPI: 1881404853
Provider Name (Legal Business Name): MARY RUGOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAGGIE RUGOLO

II. Dates (important events)

Enumeration Date: 01/10/2025
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2851 CAMINO DEL RIO S STE 300
SAN DIEGO CA
92108-3814
US

IV. Provider business mailing address

6540 REFLECTION DR APT 1101
SAN DIEGO CA
92124-5133
US

V. Phone/Fax

Practice location:
  • Phone: 760-500-3325
  • Fax:
Mailing address:
  • Phone: 908-507-6305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: