Basic Information
| Provider Information | |||||||||
| NPI: | 1134411721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAMAYO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | HERNAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23502 LYONS AVENUE | ||||||||
| Address2: | SUITE 304A | ||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617020166 | ||||||||
| FaxNumber: | 6617020169 | ||||||||
| Practice Location | |||||||||
| Address1: | 23502 LYONS AVE. | ||||||||
| Address2: | SUITE 304A | ||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617020166 | ||||||||
| FaxNumber: | 6617020169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2011 | ||||||||
| LastUpdateDate: | 07/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-06-2126 | CA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-17-25948 | CO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 0-06-2126 | 01 | CA | BCABA | OTHER | 1-17-25948 | 01 | CO | BCBA | OTHER |