Provider Demographics
NPI:1871039073
Name:CHWEKUN, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:CHWEKUN
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 1:2781 SCHENLEY TER
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-4031
Mailing Address - Country:US
Mailing Address - Phone:858-254-2431
Mailing Address - Fax:978-389-5807
Practice Address - Street 1:2781 SCHENLEY TER
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-4031
Practice Address - Country:US
Practice Address - Phone:858-254-2431
Practice Address - Fax:978-389-5807
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32172106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist