Provider Demographics
NPI:1609980234
Name:PASTORES, GLEN F
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:F
Last Name:PASTORES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 HOTEL CIR S STE 380
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3318
Mailing Address - Country:US
Mailing Address - Phone:858-987-4848
Mailing Address - Fax:
Practice Address - Street 1:2220 CAMINO DE LA REINA UNIT 311
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-5528
Practice Address - Country:US
Practice Address - Phone:619-862-9595
Practice Address - Fax:619-862-9595
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 41861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist