Basic Information
| Provider Information | |||||||||
| NPI: | 1427526755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ASW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 250 EXECUTIVE PARK BLVD STE 4900 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941343335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156560116 | ||||||||
| FaxNumber: | 4156560117 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 EXECUTIVE PARK BLVD STE 4900 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941343335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156560116 | ||||||||
| FaxNumber: | 4156560117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2018 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | ASW76899 | CA | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | ASW76899 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 390200000X | ACSW76899 | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 109822 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1427526755 | 05 | CA | MEDICAID |