=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124849658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN DIEGO STATE UNIVERSITY - HEALTHY EARLY YEARS CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2024
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4283 EL CAJON BLVD SUITE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-530-0122
-----------------------------------------------------
Fax | 619-530-0822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5500 CAMPANILE DR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92182-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-594-6017
-----------------------------------------------------
Fax | 619-594-5917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE VP OF FINANCIAL OPERATION
-----------------------------------------------------
Name | AGNES WONG NICKERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-594-6017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------