Healthcare Provider Details

I. General information

NPI: 1457731192
Provider Name (Legal Business Name): KATHRYN ZOE SPAVENTA-VANCIL M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4275 EL CAJON BLVD STE 100
SAN DIEGO CA
92105-1293
US

IV. Provider business mailing address

6176 TOOLEY ST
SAN DIEGO CA
92114-1333
US

V. Phone/Fax

Practice location:
  • Phone: 619-478-8340
  • Fax:
Mailing address:
  • Phone: 805-708-3365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY28782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: