Healthcare Provider Details

I. General information

NPI: 1649731464
Provider Name (Legal Business Name): MISS TYENNE SAVANNAH SLAWINSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 E CONVENTION CENTER WAY STE 103
ONTARIO CA
91764-5449
US

IV. Provider business mailing address

11967 ARDMOOR CT
RANCHO CUCAMONGA CA
91739-2504
US

V. Phone/Fax

Practice location:
  • Phone: 909-259-5600
  • Fax:
Mailing address:
  • Phone: 909-518-7426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberF8006116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: