Healthcare Provider Details

I. General information

NPI: 1437790904
Provider Name (Legal Business Name): EIRENA ELIZABETH EWERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8885 RIO SAN DIEGO DR STE 340
SAN DIEGO CA
92108-1669
US

IV. Provider business mailing address

250 CHERRY LN STE 109
MANTECA CA
95337-4397
US

V. Phone/Fax

Practice location:
  • Phone: 619-795-9925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: