MEDICARE: TALISSA ARLEEN CAMACHO-SEPULVEDA

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
1	106H00000X	Marriage & Family Therapist	LMFT106031	CA

General Provider Information

NPI Number	:	1356471866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TALISSA ARLEEN CAMACHO-SEPULVEDA

Provider Business Mailing Address
First Line	:	1196 3RD AVE
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3131
Country	:	US
Telephone Number	:	619-427-4661
Fax Number	:	619-426-7849

Provider Business Practice Location Address
First Line	:	1196 3RD AVE
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3131
Country	:	US
Telephone Number	:	619-427-4661
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/22/2019

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