Provider Demographics
NPI:1154065472
Name:QUICHOCHO, TYRA
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:QUICHOCHO
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 1:4030 MOORPARK AVE STE MOORPARK
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-4103
Mailing Address - Country:US
Mailing Address - Phone:669-205-1778
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:4030 MOORPARK AVE STE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-4103
Practice Address - Country:US
Practice Address - Phone:669-205-1778
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician