Provider Demographics
NPI:1922762566
Name:VERA, PEBBLES T
Entity Type:Individual
Prefix:
First Name:PEBBLES
Middle Name:T
Last Name:VERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 WHISPER DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1910
Mailing Address - Country:US
Mailing Address - Phone:808-202-1335
Mailing Address - Fax:
Practice Address - Street 1:3355 MISSION AVE STE 221
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1328
Practice Address - Country:US
Practice Address - Phone:915-813-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician