Healthcare Provider Details

I. General information

NPI: 1639711435
Provider Name (Legal Business Name): MARIA ISABEL TAMAYO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2019
Last Update Date: 01/05/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N D ST. SUITE #412, 408
SAN BERNARDINO CA
92401-1735
US

IV. Provider business mailing address

PO BOX 53413
IRVINE CA
92619-3413
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-5905
  • Fax: 951-788-5903
Mailing address:
  • Phone: 657-236-1287
  • Fax: 714-333-4535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1117508
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: