Healthcare Provider Details

I. General information

NPI: 1740103613
Provider Name (Legal Business Name): ZACHARY SERVINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2859 EL CAJON BLVD UNIT 200
SAN DIEGO CA
92104-1292
US

IV. Provider business mailing address

2859 EL CAJON BLVD UNIT 200
SAN DIEGO CA
92104-1292
US

V. Phone/Fax

Practice location:
  • Phone: 866-420-2524
  • Fax: 866-420-2524
Mailing address:
  • Phone: 866-420-2524
  • Fax: 866-420-2524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number164705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: