Provider Demographics
NPI:1396386470
Name:CONTRERAS-JERONIMO, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:CONTRERAS-JERONIMO
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 1:116 BONITA LN
Mailing Address - Street 2:
Mailing Address - City:MOSS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:94038-9766
Mailing Address - Country:US
Mailing Address - Phone:650-438-6188
Mailing Address - Fax:
Practice Address - Street 1:800 S CLAREMONT ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-1451
Practice Address - Country:US
Practice Address - Phone:650-281-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF3620903106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician