Healthcare Provider Details

I. General information

NPI: 1174735351
Provider Name (Legal Business Name): MS. ELIZABETH TENNIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HOWE AVE
SACRAMENTO CA
95825-4731
US

IV. Provider business mailing address

4420 OAKHOLLOW DR APT 95
SACRAMENTO CA
95842-4024
US

V. Phone/Fax

Practice location:
  • Phone: 916-441-0123
  • Fax:
Mailing address:
  • Phone: 916-628-1021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: