Healthcare Provider Details

I. General information

NPI: 1164259172
Provider Name (Legal Business Name): AMY TELLEZ PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E D ST
ONTARIO CA
91764-4405
US

IV. Provider business mailing address

950 W D ST
ONTARIO CA
91762-3026
US

V. Phone/Fax

Practice location:
  • Phone: 909-983-4116
  • Fax: 909-459-2906
Mailing address:
  • Phone: 909-983-4116
  • Fax: 909-459-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number230043769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: