Healthcare Provider Details

I. General information

NPI: 1285074302
Provider Name (Legal Business Name): HENRY ANTONIO CUELLAR AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 KENYON ST
SAN DIEGO CA
92110-5001
US

IV. Provider business mailing address

3420 KENYON ST
SAN DIEGO CA
92110-5001
US

V. Phone/Fax

Practice location:
  • Phone: 714-655-5083
  • Fax:
Mailing address:
  • Phone: 714-655-5083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116531
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number130124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: