=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376294686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY HOLCOMB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2022
-----------------------------------------------------
Last Update Date | 09/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 SPRING ST STE 203
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-0273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-549-0329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5638 LAKE MURRAY BLVD # 136
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-324-4332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 16819
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------