Provider Demographics
NPI:1457012361
Name:TATE, BREANNA NICOLE (MSW)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICOLE
Last Name:TATE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7350 KIRKWOOD PL
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-6224
Mailing Address - Country:US
Mailing Address - Phone:909-838-1534
Mailing Address - Fax:
Practice Address - Street 1:301 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-7131
Practice Address - Country:US
Practice Address - Phone:949-642-2734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker