Healthcare Provider Details

I. General information

NPI: 1134180037
Provider Name (Legal Business Name): MARYBETH CHRUDEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 ACADEMY DR
SOLANA BEACH CA
92075
US

IV. Provider business mailing address

767 ACADEMY DR
SOLANA BEACH CA
92075
US

V. Phone/Fax

Practice location:
  • Phone: 858-481-7346
  • Fax: 858-793-4406
Mailing address:
  • Phone: 858-481-7346
  • Fax: 858-793-4406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW10349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: