Provider Demographics
NPI:1063234730
Name:ELRICK, JOANNA K
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:K
Last Name:ELRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2602
Mailing Address - Country:US
Mailing Address - Phone:619-418-4113
Mailing Address - Fax:
Practice Address - Street 1:3594 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4940
Practice Address - Country:US
Practice Address - Phone:619-296-1151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-XLWJDP175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist