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NPI Code Detail

MEDICARE: MS. MYRA SEPULVEDA BUBY LCSW

MEDICARE: MS. MYRA SEPULVEDA BUBY LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial Worker23172CA

General Provider Information

NPI Number : 1093747511
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MYRA SEPULVEDA BUBY LCSW
Provider Business Mailing Address
First Line : 823 GATEWAY CENTER WAY
Second Line :
City : SAN DIEGO
State : CA
Zip : 92102-4541
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2204 NATIONAL AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92113-3615
Country : US
Telephone Number : 619-515-2300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/07/2006
Last Update Date : 05/11/2023

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