Provider Demographics
NPI:1063749067
Name:PICHARDO, VICKY MARIA
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:MARIA
Last Name:PICHARDO
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 1:473 E CARNEGIE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4201
Mailing Address - Country:US
Mailing Address - Phone:442-207-8459
Mailing Address - Fax:
Practice Address - Street 1:473 E CARNEGIE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4201
Practice Address - Country:US
Practice Address - Phone:442-207-8459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
CA743081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker