Healthcare Provider Details

I. General information

NPI: 1144437971
Provider Name (Legal Business Name): LUISITO GONZALES SUBIDO M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LOUIE SUBIDO M.A.

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

4534 GEORGIA ST APT 1
SAN DIEGO CA
92116-2640
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-4011
  • Fax: 858-278-2365
Mailing address:
  • Phone: 619-708-0312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 46594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: