Healthcare Provider Details

I. General information

NPI: 1548759038
Provider Name (Legal Business Name): DIANE BRESKE ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 NATIONAL AVE
SAN DIEGO CA
92113-2209
US

IV. Provider business mailing address

4864 PESCADERO AVE
SAN DIEGO CA
92107-3415
US

V. Phone/Fax

Practice location:
  • Phone: 619-255-5329
  • Fax:
Mailing address:
  • Phone: 707-319-3686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number82098
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number82098
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: