1083716120 NPI number — MS. CHRISTINE ARLENE PEMBERTON LCSW

Table of content: MS. CHRISTINE ARLENE PEMBERTON LCSW (NPI 1083716120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083716120 NPI number — MS. CHRISTINE ARLENE PEMBERTON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEMBERTON
Provider First Name:
CHRISTINE
Provider Middle Name:
ARLENE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083716120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3035 MYRTLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92104-4250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-302-5899
Provider Business Mailing Address Fax Number:
619-528-8054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3420 KENYON STREET
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-302-5899
Provider Business Practice Location Address Fax Number:
618-528-8054
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS16760 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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