Basic Information
| Provider Information | |||||||||
| NPI: | 1285917476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TELLEZ | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CAADE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 335 QUARRY RD | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940706217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505958165 | ||||||||
| FaxNumber: | 6505958167 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 QUARRY RD | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940706217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505958165 | ||||||||
| FaxNumber: | 6505958167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2011 | ||||||||
| LastUpdateDate: | 09/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 092000 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.