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General NPI Number Information
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NPI Number | 1639997927
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Entity Type | Individual
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Provider Name | ELIZA BOURKE
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Gender |
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Dates
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Enumeration Date | 09/26/2024
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Last Update Date | 08/06/2025
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Provider Practice Location Address
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Address Line | 1260 MORENA BLVD STE 2
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City | SAN DIEGO
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State | CA
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Zip | 92110-3889
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Country | US
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Telephone | 619-398-3261
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Fax |
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Provider Business Mailing Address
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Address Line | 1260 MORENA BLVD STE 200
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City | SAN DIEGO
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State | CA
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Zip | 92110-3850
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Country | US
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Telephone | 619-323-7271
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | A15666
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 225400000X
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Taxonomy Name | Rehabilitation Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | ASW130714
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License Number State | CA
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