Healthcare Provider Details

I. General information

NPI: 1962797407
Provider Name (Legal Business Name): TANYA P. L. CARCAMO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TANYA P. LOPEZ MFT-INTERN

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S G ST
SAN BERNARDINO CA
92410-3320
US

IV. Provider business mailing address

PO BOX 6183
MORENO VALLEY CA
92554-6183
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4800
  • Fax: 909-771-2833
Mailing address:
  • Phone: 951-314-6743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number67049
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number87293
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: