Basic Information
| Provider Information | |||||||||
| NPI: | 1871640110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FATTORE | ||||||||
| FirstName: | TANIA | ||||||||
| MiddleName: | MARCELA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVAS | ||||||||
| OtherFirstName: | TANIA | ||||||||
| OtherMiddleName: | MARCELA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 265 SAN JACINTO RIVER RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925304400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516749243 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 265 SAN JACINTO RIVER RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925304400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516749243 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 69009 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.