Healthcare Provider Details

I. General information

NPI: 1154207991
Provider Name (Legal Business Name): BREANNA DOMONIQUE TREJO I SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5473 KEARNY VILLA RD
SAN DIEGO CA
92123-1150
US

IV. Provider business mailing address

5473 KEARNY VILLA RD
SAN DIEGO CA
92123-1150
US

V. Phone/Fax

Practice location:
  • Phone: 855-325-8428
  • Fax:
Mailing address:
  • Phone: 855-325-8428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18152
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: