NPIMap

Organization Active NPI

San Diego State University - Healthy Early Years Clinic

  • Counselor
  • San Diego, CA
National Provider Identifier
1124849658
Registry record updated Oct 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
CounselorTaxonomy code 101Y00000X
Legal business name
SAN DIEGO STATE UNIVERSITY - HEALTHY EARLY YEARS CLINIC
Practice address
4283 El Cajon Blvd
Suite 200
San Diego, CA 92105
Phone
(619) 530-0122
Fax
(619) 530-0822
NPI assigned
Oct 17, 2024
Last updated
Oct 17, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SAN DIEGO STATE UNIVERSITYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 17, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Agnes Wong Nickerson
Title
Associate VP of Financial Operation
Phone
(619) 594-6017

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101Y00000X Primary
Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 104100000X
Marriage & Family TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 106H00000X

Addresses

Primary practice location

4283 El Cajon Blvd
Suite 200
San Diego, CA 92105

Mailing address

5500 Campanile Dr
San Diego, CA 92182-1518
Phone (619) 594-6017

National Provider Directory

National Provider Directory
Tax ID family
San Diego State University Student Health Services4 organizations share this tax ID, including this one
Part of
San Diego State University Student Health Services

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4283 El Cajon Blvd
Ste 200
San Diego, CA 92105
Phone (619) 371-5420

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1729123200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729123200000",
    "number": "1124849658",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5500 CAMPANILE DR",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921821518",
            "telephone_number": "619-594-6017",
            "fax_number": "619-594-5917"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4283 EL CAJON BLVD",
            "address_2": "SUITE 200",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "92105",
            "telephone_number": "619-530-0122",
            "fax_number": "619-530-0822"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAN DIEGO STATE UNIVERSITY - HEALTHY EARLY YEARS CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SAN DIEGO STATE UNIVERSITY",
        "enumeration_date": "2024-10-17",
        "last_updated": "2024-10-17",
        "status": "A",
        "authorized_official_last_name": "WONG NICKERSON",
        "authorized_official_first_name": "AGNES",
        "authorized_official_title_or_position": "ASSOCIATE VP OF FINANCIAL OPERATION",
        "authorized_official_telephone_number": "619-594-6017"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Marriage & Family Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in San Diego, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.