Healthcare Provider Details

I. General information

NPI: 1164332987
Provider Name (Legal Business Name): ESPACIO INDIVIDUAL AND FAMILY THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8885 RIO SAN DIEGO DR STE 106
SAN DIEGO CA
92108-1907
US

IV. Provider business mailing address

8885 RIO SAN DIEGO DR STE 106
SAN DIEGO CA
92108-1907
US

V. Phone/Fax

Practice location:
  • Phone: 619-914-6853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. ALICIA LEE FONG
Title or Position: OWNER
Credential:
Phone: 619-717-9636