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General NPI Number Information
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NPI Number | 1144645649
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Entity Type | Individual
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Provider Name | JESSIE TIVAO
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Gender | Male
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Dates
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Enumeration Date | 02/20/2014
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Last Update Date | 05/26/2023
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Provider Practice Location Address
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Address Line | 1045 W REDONDO BEACH BLVD FL 3
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City | GARDENA
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State | CA
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Zip | 90247-4128
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Country | US
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Telephone | 310-970-5000
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Fax | 323-967-0614
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Provider Business Mailing Address
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Address Line | 1045 W REDONDO BLVD 3RD FLOOR
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City | GARDENA
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State | CA
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Zip | 90247
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Country | US
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Telephone | 310-970-5000
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Fax | 323-967-0614
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | ASW111726
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License Number State | CA
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