Healthcare Provider Details

I. General information

NPI: 1306438726
Provider Name (Legal Business Name): RUBEN TINAJERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 UNIVERSITY TOWN CENTRE DR
MORGANTOWN WV
26501-2421
US

IV. Provider business mailing address

6040 UNIVERSITY TOWN CENTRE DR
MORGANTOWN WV
26501-2421
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1279
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1279
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: