Provider Demographics
NPI:1447963475
Name:PADILLA, ISSAC E
Entity type:Individual
Prefix:
First Name:ISSAC
Middle Name:E
Last Name:PADILLA
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 1:4179 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-1843
Mailing Address - Country:US
Mailing Address - Phone:619-433-2665
Mailing Address - Fax:
Practice Address - Street 1:3132 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4421
Practice Address - Country:US
Practice Address - Phone:619-683-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-346144106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician