Healthcare Provider Details

I. General information

NPI: 1174298368
Provider Name (Legal Business Name): SASHA MICHELLE LIZARDI LUQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 CAMINO DE LA REINA STE 210
SAN DIEGO CA
92108-3104
US

IV. Provider business mailing address

591 CAMINO DE LA REINA STE 210
SAN DIEGO CA
92108-3104
US

V. Phone/Fax

Practice location:
  • Phone: 619-206-5271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17100
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: