Provider Demographics
NPI:1891366910
Name:VALENITN TATE, TYEQUAAN LEROY
Entity Type:Individual
Prefix:
First Name:TYEQUAAN
Middle Name:LEROY
Last Name:VALENITN TATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TY
Other - Middle Name:
Other - Last Name:VALENTIN TATE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6 SAND HILL RD
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-1306
Mailing Address - Country:US
Mailing Address - Phone:215-433-6442
Mailing Address - Fax:
Practice Address - Street 1:45 U.S. 11
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876
Practice Address - Country:US
Practice Address - Phone:570-802-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician