Provider Demographics
NPI:1275627168
Name:DWECK, S. STEVAN (PHD)
Entity Type:Individual
Prefix:
First Name:S.
Middle Name:STEVAN
Last Name:DWECK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 SEACREST DR.
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1231
Mailing Address - Country:US
Mailing Address - Phone:949-760-2525
Mailing Address - Fax:
Practice Address - Street 1:4715 VIEWRIDGE AVE
Practice Address - Street 2:# 230
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1680
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8192103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY081920Medicaid
CAWCP8192AMedicare ID - Type Unspecified