Provider Demographics
NPI:1477848182
Name:PAYTON-MORTALONI, NICHOLAS ANTHONY (LCSW)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANTHONY
Last Name:PAYTON-MORTALONI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:ANTHONY
Other - Last Name:MORTALONI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3255 WING ST
Mailing Address - Street 2:SAN DIEGO YOUTH SERVICES
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4638
Mailing Address - Country:US
Mailing Address - Phone:619-221-8600
Mailing Address - Fax:619-221-8611
Practice Address - Street 1:3255 WING ST
Practice Address - Street 2:SAN DIEGO YOUTH SERVICES
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4638
Practice Address - Country:US
Practice Address - Phone:619-221-8600
Practice Address - Fax:619-221-8611
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA264761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical