Provider Demographics
NPI:1760194575
Name:SAN JUAN, DEBORAH LYNNE (LCSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LYNNE
Last Name:SAN JUAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DEBORAN
Other - Middle Name:LYNNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2825 PRESTWICK CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7873
Mailing Address - Country:US
Mailing Address - Phone:707-580-8273
Mailing Address - Fax:
Practice Address - Street 1:2825 PRESTWICK CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-7873
Practice Address - Country:US
Practice Address - Phone:707-580-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA808251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA80825OtherBOARD OF BEHAVIORAL HEALTH