Provider Demographics
NPI:1821604232
Name:CENTENO LOPEZ, TAMARA ELIZABETH
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ELIZABETH
Last Name:CENTENO LOPEZ
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 1:3410 BEN LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-5614
Mailing Address - Country:US
Mailing Address - Phone:209-471-9527
Mailing Address - Fax:
Practice Address - Street 1:19 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4107
Practice Address - Country:US
Practice Address - Phone:209-835-8583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8344101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health