Healthcare Provider Details

I. General information

NPI: 1164336269
Provider Name (Legal Business Name): GLOW WITH WELLNESS THERAPY, LICENSED CLINICAL SOCIAL WORKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 ROSECRANS ST STE 114-134
SAN DIEGO CA
92110-3231
US

IV. Provider business mailing address

3555 ROSECRANS ST STE 114-134
SAN DIEGO CA
92110-3231
US

V. Phone/Fax

Practice location:
  • Phone: 858-326-1810
  • Fax: 858-326-2043
Mailing address:
  • Phone: 858-326-1810
  • Fax: 858-326-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHEILA KUBOTA
Title or Position: PRESIDENT/CEO
Credential: LCSW, PMH-C
Phone: 858-326-1810