Provider Demographics
NPI:1518161165
Name:TENENBAUM, MYRNA W (IMF)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:W
Last Name:TENENBAUM
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11233 TIERRASANTA BLVD APT 33
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2800
Mailing Address - Country:US
Mailing Address - Phone:858-505-8003
Mailing Address - Fax:
Practice Address - Street 1:835 3RD AVE
Practice Address - Street 2:SUITE E
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-585-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF42804101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health