Healthcare Provider Details

I. General information

NPI: 1972794485
Provider Name (Legal Business Name): TAMMY ANN JAVONILLO LICENSED PSYCH TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 REDONDO AVE
LONG BEACH CA
90806-2325
US

IV. Provider business mailing address

2600 REDONDO AVE
LONG BEACH CA
90806-2325
US

V. Phone/Fax

Practice location:
  • Phone: 562-256-2900
  • Fax: 562-290-0074
Mailing address:
  • Phone: 562-256-2900
  • Fax: 562-290-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT34326
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: