Healthcare Provider Details

I. General information

NPI: 1881278703
Provider Name (Legal Business Name): NASTASSJAVARGASLICENSEDCLINICALSOCIALWORKER.INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 PARK BLVD STE 102-156
SAN DIEGO CA
92103-2670
US

IV. Provider business mailing address

4075 PARK BLVD STE 102-156
SAN DIEGO CA
92103-2670
US

V. Phone/Fax

Practice location:
  • Phone: 619-786-6402
  • Fax:
Mailing address:
  • Phone: 619-786-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NASTASSJA RACHELLE VARGAS
Title or Position: OWNER/DIRECTOR
Credential: LCSW
Phone: 619-786-6402