Provider Demographics
NPI:1831526094
Name:ESTRADA, TANIA (PSYCH TECH LICENSE)
Entity type:Individual
Prefix:MS
First Name:TANIA
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:PSYCH TECH LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16845 SAN BERNARDINO AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-9225
Mailing Address - Country:US
Mailing Address - Phone:909-319-5525
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:562-781-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 36114167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician