Basic Information
| Provider Information | |||||||||
| NPI: | 1477175883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPACT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY RESEARCH FOUNDATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1260 MORENA BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192324357 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1260 MORENA BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192324357 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2020 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANCHEZ | ||||||||
| AuthorizedOfficialFirstName: | TESSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LEAD HR SPECIALIST -ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6192750822 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 251S00000X | N | Agencies | Community/Behavioral Health | 164W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 201902804LPN | 01 | OR | LICENSE PRACTICAL NURSE | OTHER | 719792 | 01 | CA | CALIFORNIA BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS | OTHER | VN719792 | 01 | CA | LICENSE VOCATIONAL NURSE | OTHER |