1891879474 NPI number — MS. TAMARA YVETTE PRENTICE LICENSED PSYCH TECH

Table of content: MS. TAMARA YVETTE PRENTICE LICENSED PSYCH TECH (NPI 1891879474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891879474 NPI number — MS. TAMARA YVETTE PRENTICE LICENSED PSYCH TECH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRENTICE
Provider First Name:
TAMARA
Provider Middle Name:
YVETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED PSYCH TECH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891879474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 S VERMONT AVE
Provider Second Line Business Mailing Address:
EOB/PMRT 10TH FLOOR
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90020-1912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-258-2004
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4024 DURFEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL MONTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91732-2510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-258-2004
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 167G00000X , with the licence number:  PT 30071 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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