Provider Demographics
NPI:1649731464
Name:SLAWINSKI, TYENNE SAVANNAH
Entity type:Individual
Prefix:MISS
First Name:TYENNE
Middle Name:SAVANNAH
Last Name:SLAWINSKI
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 1:11967 ARDMOOR CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2504
Mailing Address - Country:US
Mailing Address - Phone:909-518-7426
Mailing Address - Fax:
Practice Address - Street 1:2151 E CONVENTION CENTER WAY STE 103
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5449
Practice Address - Country:US
Practice Address - Phone:909-259-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF8006116106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician