Healthcare Provider Details

I. General information

NPI: 1821604232
Provider Name (Legal Business Name): TAMARA ELIZABETH CENTENO LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 E 6TH ST
TRACY CA
95376-4107
US

IV. Provider business mailing address

3410 BEN LN
STOCKTON CA
95206-5614
US

V. Phone/Fax

Practice location:
  • Phone: 209-835-8583
  • Fax:
Mailing address:
  • Phone: 209-471-9527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: