Healthcare Provider Details

I. General information

NPI: 1447017488
Provider Name (Legal Business Name): MARK JUDE RYWELSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 DALE ST
SAN DIEGO CA
92102-1519
US

IV. Provider business mailing address

2980 CEDAR ST
SAN DIEGO CA
92102-1599
US

V. Phone/Fax

Practice location:
  • Phone: 619-915-5710
  • Fax:
Mailing address:
  • Phone: 619-239-7370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1538671223
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: