Healthcare Provider Details

I. General information

NPI: 1093747511
Provider Name (Legal Business Name): MYRA SEPULVEDA BUBY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 NATIONAL AVE
SAN DIEGO CA
92113-3615
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number23172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: