Provider Demographics
NPI:1982995072
Name:BOCALAN, SID
Entity Type:Individual
Prefix:
First Name:SID
Middle Name:
Last Name:BOCALAN
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 1:3340 KEMPER ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4907
Mailing Address - Country:US
Mailing Address - Phone:619-523-8121
Mailing Address - Fax:
Practice Address - Street 1:3340 KEMPER ST STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4907
Practice Address - Country:US
Practice Address - Phone:619-523-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAASW108075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA373781Medicaid