Healthcare Provider Details

I. General information

NPI: 1609992262
Provider Name (Legal Business Name): DEBORAH CAREN PONTILLO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HIGH BLUFF DR SUITE #101
SAN DIEGO CA
92130-2052
US

IV. Provider business mailing address

12625 HIGH BLUFF DR SUITE #101
SAN DIEGO CA
92130-2052
US

V. Phone/Fax

Practice location:
  • Phone: 858-692-4187
  • Fax:
Mailing address:
  • Phone: 858-692-4187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number18934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: