1689822538 NPI number — TAMMY GAY CLEARY

Table of content: TAMMY GAY CLEARY (NPI 1689822538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689822538 NPI number — TAMMY GAY CLEARY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEARY
Provider First Name:
TAMMY
Provider Middle Name:
GAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689822538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17401 IRVINE BLVD
Provider Second Line Business Mailing Address:
SUITE J
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-3038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-734-4244
Provider Business Mailing Address Fax Number:
714-983-2333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17401 IRVINE BLVD
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-3038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-734-4244
Provider Business Practice Location Address Fax Number:
714-983-2333
Provider Enumeration Date:
09/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY24393 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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