1962973842 NPI number — VERONNA BONGGAT DIZON LCSW, PMH-C

Table of content: VERONNA BONGGAT DIZON LCSW, PMH-C (NPI 1962973842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962973842 NPI number — VERONNA BONGGAT DIZON LCSW, PMH-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIZON
Provider First Name:
VERONNA
Provider Middle Name:
BONGGAT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, PMH-C
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:
1962973842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 212732
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHULA VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91921-2732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-403-9772
Provider Business Mailing Address Fax Number:
619-354-7228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
918 LAFAYETTE PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91913-3158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-482-3804
Provider Business Practice Location Address Fax Number:
619-354-7228
Provider Enumeration Date:
12/17/2018

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:  26421 , 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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