Provider Demographics
NPI:1124849658
Name:SAN DIEGO STATE UNIVERSITY - HEALTHY EARLY YEARS CLINIC
Entity type:Organization
Organization Name:SAN DIEGO STATE UNIVERSITY - HEALTHY EARLY YEARS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE VP OF FINANCIAL OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-594-6017
Mailing Address - Street 1:5500 CAMPANILE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92182-1518
Mailing Address - Country:US
Mailing Address - Phone:619-594-6017
Mailing Address - Fax:619-594-5917
Practice Address - Street 1:4283 EL CAJON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105
Practice Address - Country:US
Practice Address - Phone:619-530-0122
Practice Address - Fax:619-530-0822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN DIEGO STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty