=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184836215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF SAN DIEGO, AGING & INDEPENDANCE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4858 DEL MAR AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-739-6152
-----------------------------------------------------
Fax | 760-739-6154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4858 DEL MAR AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-739-6152
-----------------------------------------------------
Fax | 760-739-6154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR TEAM
-----------------------------------------------------
Name | MS. GAIL MARIE MCGVIEN I
-----------------------------------------------------
Credential | MFT
-----------------------------------------------------
Telephone | 760-739-6152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MFC36490
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------