Basic Information
| Provider Information | |||||||||
| NPI: | 1396948576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IACUANIELLO | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4307 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921031407 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3480 BUSKIRK AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945234304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259332627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | LCSW80159 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.