Provider Demographics
NPI:1073107405
Name:CARGILL, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CARGILL
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 1:13374 KIBBINGS RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-1233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225800000X
CT002840106H00000X
CAAMFT123587106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
64993OtherNCTRC
CAAMFT123587OtherBOARD OF BEHAVIORAL SCIENCES