Healthcare Provider Details

I. General information

NPI: 1821298753
Provider Name (Legal Business Name): CARMENCITA GISELLE BERSAMIN BORILLO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARMENCITA GISELLE BERSAMIN BRINGAS

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-8686
  • Fax: 209-468-2380
Mailing address:
  • Phone: 209-468-8686
  • Fax: 209-468-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number51469
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number51469
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT53691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: