Provider Demographics
NPI:1942567367
Name:NGUYEN, AILY THI (CATC #167680)
Entity Type:Individual
Prefix:
First Name:AILY
Middle Name:THI
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:CATC #167680
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2555
Mailing Address - Fax:
Practice Address - Street 1:2136 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1102
Practice Address - Country:US
Practice Address - Phone:619-906-4663
Practice Address - Fax:619-269-8349
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA167680101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)