=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568009421
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERBERT TEZENO JR. OTA, BSW, MSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2019
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41197 GOLDEN GATE CIR STE 201
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92562-6999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-409-8856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31937 HONEYSUCKLE CT
-----------------------------------------------------
City | LAKE ELSINORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92532-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-254-0923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA2005
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ASW113520
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------