Provider Demographics
NPI:1568009421
Name:TEZENO, HERBERT JR (OTA, BSW)
Entity Type:Individual
Prefix:MR
First Name:HERBERT
Middle Name:
Last Name:TEZENO
Suffix:JR
Gender:M
Credentials:OTA, BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31937 HONEYSUCKLE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2519
Mailing Address - Country:US
Mailing Address - Phone:619-254-0923
Mailing Address - Fax:
Practice Address - Street 1:36330 HIDDEN SPRINGS RD STE E6
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-5803
Practice Address - Country:US
Practice Address - Phone:619-254-0923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CAOTA2005224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty