Provider Demographics
NPI:1396214615
Name:TETRA HEALTH CARE
Entity Type:Organization
Organization Name:TETRA HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:LISE
Authorized Official - Last Name:ESSOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:310-925-5542
Mailing Address - Street 1:10714 WOODBINE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5423
Mailing Address - Country:US
Mailing Address - Phone:310-925-5542
Mailing Address - Fax:
Practice Address - Street 1:10714 WOODBINE ST APT 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-5423
Practice Address - Country:US
Practice Address - Phone:310-925-5542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700331956Medicaid