Healthcare Provider Details

I. General information

NPI: 1073107405
Provider Name (Legal Business Name): HEATHER CARGILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

13374 KIBBINGS RD
SAN DIEGO CA
92130-1233
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number002840
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT123587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: