Provider Demographics
NPI:1417237181
Name:ZAMUDIO, MARIANELA (MSED)
Entity Type:Individual
Prefix:
First Name:MARIANELA
Middle Name:
Last Name:ZAMUDIO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 MONTE SERENO AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1405
Mailing Address - Country:US
Mailing Address - Phone:619-420-4470
Mailing Address - Fax:
Practice Address - Street 1:5005 TEXAS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3721
Practice Address - Country:US
Practice Address - Phone:619-692-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA205837239Medicaid