Basic Information
| Provider Information | |||||||||
| NPI: | 1174101737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELL | ||||||||
| FirstName: | TAJANIQUE | ||||||||
| MiddleName: | VELANI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 FAIRWAY DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334411834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774182987 | ||||||||
| FaxNumber: | 8665002186 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 GRAND CANAL BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952078107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107468693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2021 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 206KQP3H | 05 | CA | MEDICAID |