=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538569538
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICE P. WU-CARDONA LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2014
-----------------------------------------------------
Last Update Date | 11/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8715 BLUE LAKE DR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92119-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-759-6166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4231 BALBOA AVE # 553
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-759-6166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 93432
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------