Basic Information
| Provider Information | |||||||||
| NPI: | 1962797407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARCAMO | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | P. L. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOPEZ | ||||||||
| OtherFirstName: | TANYA | ||||||||
| OtherMiddleName: | P. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MFT-INTERN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6183 | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925546183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513146743 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 250 S G ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584800 | ||||||||
| FaxNumber: | 9097712833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 67049 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 87293 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.