Provider Demographics
NPI:1841786498
Name:PATIMETEEPORN, TANYA (MSW)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:PATIMETEEPORN
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 1:14075 HESPERIA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4500
Mailing Address - Country:US
Mailing Address - Phone:760-810-0000
Mailing Address - Fax:
Practice Address - Street 1:14075 HESPERIA RD STE 101
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4500
Practice Address - Country:US
Practice Address - Phone:760-810-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83181101YM0800X, 104100000X
CA1011111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker