Provider Demographics
NPI:1922762012
Name:APODACA, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:APODACA
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 1:419 PENNSYLVANIA ST # A
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-6933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:419 PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-6933
Practice Address - Country:US
Practice Address - Phone:707-643-2715
Practice Address - Fax:707-643-8536
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1412621220101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1412621220OtherCCAPP