1396071494 NPI number — MRS. ERICKA MANCILLAS VARGAS BA PSYCHOLOGY

Table of content: MRS. ERICKA MANCILLAS VARGAS BA PSYCHOLOGY (NPI 1396071494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396071494 NPI number — MRS. ERICKA MANCILLAS VARGAS BA PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARGAS
Provider First Name:
ERICKA
Provider Middle Name:
MANCILLAS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BA PSYCHOLOGY
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VARGAS
Provider Other First Name:
ERICKA
Provider Other Middle Name:
MANCILLAS
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA PSYCHOLOGY
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1396071494
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6160 MISSION GORGE RD STE 100
Provider Second Line Business Mailing Address:
SAN DIEGO
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92120-3425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-481-3790
Provider Business Mailing Address Fax Number:
619-481-3797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6160 MISSION GORGE RD STE 100
Provider Second Line Business Practice Location Address:
SAN DIEGO
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-481-3790
Provider Business Practice Location Address Fax Number:
619-481-3797
Provider Enumeration Date:
10/23/2009

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: 171M00000X , with the licence number:  N/A ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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