Provider Demographics
NPI:1275026452
Name:CHARNETT, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CHARNETT
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 1:210 SUTTON WAY APT 106
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4185
Mailing Address - Country:US
Mailing Address - Phone:530-788-5042
Mailing Address - Fax:
Practice Address - Street 1:1112 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6608
Practice Address - Country:US
Practice Address - Phone:805-979-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-23-67315103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician