Basic Information
Provider Information | |||||||||
NPI: | 1811336910 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEBE SAN DIEGO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8885 RIO SAN DIEGO DR STE 340 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921081669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6197959925 | ||||||||
FaxNumber: | 8776025087 | ||||||||
Practice Location | |||||||||
Address1: | 3878 RUFFIN RD STE B | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6197959925 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2013 | ||||||||
LastUpdateDate: | 03/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUNT | ||||||||
AuthorizedOfficialFirstName: | ABIGAIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6196065858 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BCBA | ||||||||
NPICertificationDate: | 03/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP |   |   |   | 106S00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP |   |   |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 103K00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.