Basic Information
| Provider Information | |||||||||
| NPI: | 1255067880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELGEZAWI | ||||||||
| FirstName: | NOUR | ||||||||
| MiddleName: | MOATAZ | ||||||||
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| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PRECISION PARK LN | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921731345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 875 EL CAJON BLVD | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920205714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2022 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 109173 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | 109173 | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.