Provider Demographics
NPI:1063041580
Name:PRIMICERIO, TOBE
Entity Type:Individual
Prefix:
First Name:TOBE
Middle Name:
Last Name:PRIMICERIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 W 9TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5994
Mailing Address - Country:US
Mailing Address - Phone:909-272-5047
Mailing Address - Fax:
Practice Address - Street 1:1260 E ARROW HWY BLDG E
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4984
Practice Address - Country:US
Practice Address - Phone:909-932-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11431101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)