Provider Demographics
NPI:1164298899
Name:ENTZMINGER, COREETHA AYESHA (MS)
Entity Type:Individual
Prefix:MS
First Name:COREETHA
Middle Name:AYESHA
Last Name:ENTZMINGER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 N PUMP HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-8022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2035 N PUMP HOUSE LN
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-8022
Practice Address - Country:US
Practice Address - Phone:805-225-4446
Practice Address - Fax:805-800-8929
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94027422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health