Provider Demographics
NPI:1154777084
Name:PALMER, JOSHUA LEE (A053780219)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:LEE
Last Name:PALMER
Suffix:
Gender:M
Credentials:A053780219
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12049 WORLD TRADE DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4680
Mailing Address - Country:US
Mailing Address - Phone:206-673-1307
Mailing Address - Fax:
Practice Address - Street 1:2970 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-3296
Practice Address - Country:US
Practice Address - Phone:619-236-9492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60153206101YA0400X
CAA053780219101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)