Healthcare Provider Details

I. General information

NPI: 1164943049
Provider Name (Legal Business Name): VANESSA SELENE TINAJERO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 11/06/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 MACORNI AVE
SACRAMENTO CA
95821
US

IV. Provider business mailing address

PO BOX 757
WEST SACRAMENTO CA
95605-0757
US

V. Phone/Fax

Practice location:
  • Phone: 916-890-3000
  • Fax:
Mailing address:
  • Phone: 916-596-3508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number96942
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: