Provider Demographics
NPI:1417532920
Name:TAMAYO, ERNESTVID III (LCSW)
Entity Type:Individual
Prefix:
First Name:ERNESTVID
Middle Name:
Last Name:TAMAYO
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 N SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1844
Mailing Address - Country:US
Mailing Address - Phone:213-503-0429
Mailing Address - Fax:
Practice Address - Street 1:1719 N SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1844
Practice Address - Country:US
Practice Address - Phone:213-503-0429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA959171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical