Provider Demographics
NPI:1699555318
Name:IDETA, JULIE ANN
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:IDETA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36368 GAMBREL GATE CT
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8680
Mailing Address - Country:US
Mailing Address - Phone:951-525-9304
Mailing Address - Fax:
Practice Address - Street 1:2204 S EL CAMINO REAL STE 315
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6390
Practice Address - Country:US
Practice Address - Phone:760-500-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist