Healthcare Provider Details

I. General information

NPI: 1841836244
Provider Name (Legal Business Name): MARY J TICHACEK RN, PMHNP-BC, PMHCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARY JO TICHACEK

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-3034
US

IV. Provider business mailing address

11515 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-3034
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax:
Mailing address:
  • Phone: 858-279-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number202048
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95024198
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number207
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: