Healthcare Provider Details

I. General information

NPI: 1023929049
Provider Name (Legal Business Name): CAMILA TAVAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 GLENWOOD AVE
MANCHESTER NH
03102-5030
US

IV. Provider business mailing address

173 GLENWOOD AVE
MANCHESTER NH
03102-5030
US

V. Phone/Fax

Practice location:
  • Phone: 603-512-7144
  • Fax:
Mailing address:
  • Phone: 603-512-7144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: