Healthcare Provider Details

I. General information

NPI: 1891879474
Provider Name (Legal Business Name): TAMARA YVETTE PRENTICE LICENSED PSYCH TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 DURFEE AVE
EL MONTE CA
91732-2510
US

IV. Provider business mailing address

550 S VERMONT AVE EOB/PMRT 10TH FLOOR
LOS ANGELES CA
90020-1912
US

V. Phone/Fax

Practice location:
  • Phone: 626-258-2004
  • Fax:
Mailing address:
  • Phone: 626-258-2004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT 30071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: