Healthcare Provider Details

I. General information

NPI: 1134147457
Provider Name (Legal Business Name): MARYLUPE FLORES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3364 BEYER BLVD
SAN YSIDRO CA
92173-1322
US

IV. Provider business mailing address

1601 PRECISION PARK LN
SAN DIEGO CA
92173-1345
US

V. Phone/Fax

Practice location:
  • Phone: 619-205-4585
  • Fax:
Mailing address:
  • Phone: 619-662-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS19815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: