Provider Demographics
NPI:1336578376
Name:EZELL, TAMIKA
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:EZELL
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 1:1053 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3521
Mailing Address - Country:US
Mailing Address - Phone:909-763-5507
Mailing Address - Fax:909-884-9035
Practice Address - Street 1:1053 N D ST
Practice Address - Street 2:BLDG. A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3521
Practice Address - Country:US
Practice Address - Phone:909-763-5507
Practice Address - Fax:909-884-9035
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF82533106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist