Provider Demographics
NPI:1689354102
Name:TELLEZ, CHASIDY SERRNIA
Entity Type:Individual
Prefix:
First Name:CHASIDY
Middle Name:SERRNIA
Last Name:TELLEZ
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 1:1537 W CENTER ST APT 184
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-4251
Mailing Address - Country:US
Mailing Address - Phone:209-702-5099
Mailing Address - Fax:
Practice Address - Street 1:1537 W CENTER ST APT 184
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4251
Practice Address - Country:US
Practice Address - Phone:209-702-5099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician