Healthcare Provider Details

I. General information

NPI: 1154097418
Provider Name (Legal Business Name): RAENA SUZANNE RAMOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12437 LEWIS ST STE 100
GARDEN GROVE CA
92840-4651
US

IV. Provider business mailing address

1270 FERMI CT
SAN JACINTO CA
92583-5229
US

V. Phone/Fax

Practice location:
  • Phone: 714-202-0118
  • Fax:
Mailing address:
  • Phone: 562-355-3458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S00000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: