Healthcare Provider Details

I. General information

NPI: 1235064304
Provider Name (Legal Business Name): ANGELICA ELIZABETH ROMERO SUDRC1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3767 CENTRAL AVE
SAN DIEGO CA
92105-2599
US

IV. Provider business mailing address

3767 CENTRAL AVE
SAN DIEGO CA
92105-2599
US

V. Phone/Fax

Practice location:
  • Phone: 619-584-4010
  • Fax: 619-278-0777
Mailing address:
  • Phone: 619-584-4010
  • Fax: 619-278-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC126740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: