Healthcare Provider Details

I. General information

NPI: 1326111360
Provider Name (Legal Business Name): DENEICE TELL LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 CARMEN LN STE K
SANTA MARIA CA
93458-7768
US

IV. Provider business mailing address

1199 E RICE RANCH RD
SANTA MARIA CA
93455-5650
US

V. Phone/Fax

Practice location:
  • Phone: 805-335-4996
  • Fax:
Mailing address:
  • Phone: 805-934-6380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number28285
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: