Healthcare Provider Details

I. General information

NPI: 1215553466
Provider Name (Legal Business Name): CRISTINA MARIANA ASCENCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 30TH ST STE K
SAN DIEGO CA
92154-3497
US

IV. Provider business mailing address

1465 30TH ST STE K
SAN DIEGO CA
92154-3497
US

V. Phone/Fax

Practice location:
  • Phone: 619-428-1000
  • Fax: 619-428-1091
Mailing address:
  • Phone: 619-428-1000
  • Fax: 619-428-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC10265
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20917
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: