Basic Information
| Provider Information | |||||||||
| NPI: | 1972150514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LONG | ||||||||
| FirstName: | TAMMI | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Credential: | AOD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24631 MEADOW CREEK CT | ||||||||
| Address2: | |||||||||
| City: | ACAMPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952209668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096421367 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1947 N CALIFORNIA ST STE B&C | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952046029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094630870 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2019 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.