Provider Demographics
NPI:1255002663
Name:TINAJERO, AXEL
Entity Type:Individual
Prefix:
First Name:AXEL
Middle Name:
Last Name:TINAJERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 NE 37TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76106-3859
Mailing Address - Country:US
Mailing Address - Phone:817-372-2693
Mailing Address - Fax:
Practice Address - Street 1:1000 SAINT LOUIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3377
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-152210106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician