Healthcare Provider Details

I. General information

NPI: 1689336299
Provider Name (Legal Business Name): DAMIAN BERMUDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 02/23/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6244 EL CAJON BLVD. STE.14
SAN DIEGO CA
92115-4528
US

IV. Provider business mailing address

6244 EL CAJON BLVD. STE. 14
SAN DIEGO CA
92115-4528
US

V. Phone/Fax

Practice location:
  • Phone: 619-206-6166
  • Fax:
Mailing address:
  • Phone: 619-206-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: