Healthcare Provider Details

I. General information

NPI: 1083924864
Provider Name (Legal Business Name): ODON JOSEPH HIDALGO LCSW,LPC,LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 VIEWRIDGE AVE SUITE 230
SAN DIEGO CA
92123-1658
US

IV. Provider business mailing address

4715 VIEWRIDGE AVE SUITE 230
SAN DIEGO CA
92123-1658
US

V. Phone/Fax

Practice location:
  • Phone: 800-257-8715
  • Fax: 858-874-8212
Mailing address:
  • Phone: 800-257-8715
  • Fax: 858-874-8212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number02851
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: