Basic Information
| Provider Information | |||||||||
| NPI: | 1669073789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELAEZ | ||||||||
| FirstName: | MIRNA | ||||||||
| MiddleName: | ANDREA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6702 KELLY ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921116526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582134124 | ||||||||
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| Practice Location | |||||||||
| Address1: | 891 KUHN DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919143551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6198647070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.