Provider Demographics
NPI:1548869175
Name:MACCIOMEI, ERYNN ELIZABETH (PHD)
Entity type:Individual
Prefix:
First Name:ERYNN
Middle Name:ELIZABETH
Last Name:MACCIOMEI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 TEMECULA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1003
Mailing Address - Country:US
Mailing Address - Phone:586-634-4464
Mailing Address - Fax:
Practice Address - Street 1:3760 CONVOY ST STE 118
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3743
Practice Address - Country:US
Practice Address - Phone:586-634-4644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY30421OtherSTATE OF CA