Provider Demographics
NPI:1912608860
Name:GARDUNO PEREZ, MAURICIO
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:GARDUNO PEREZ
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 1:1247 N LAS FLORES DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-5900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8910 UNIVERSITY CENTER LN STE 400
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1025
Practice Address - Country:US
Practice Address - Phone:603-692-8173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician