Basic Information
| Provider Information | |||||||||
| NPI: | 1023364536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAMAYO | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARIA | ||||||||
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| OtherLastName: | MILES | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | MARIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1202 MORENA BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103844 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1738 S TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920545309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604392800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2012 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.