Provider Demographics
NPI:1053013185
Name:CARRENO, ITZHARA ATAI
Entity type:Individual
Prefix:
First Name:ITZHARA
Middle Name:ATAI
Last Name:CARRENO
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 1:65 W HAWK ST
Mailing Address - Street 2:
Mailing Address - City:HEBER
Mailing Address - State:CA
Mailing Address - Zip Code:92249-9749
Mailing Address - Country:US
Mailing Address - Phone:760-336-9425
Mailing Address - Fax:
Practice Address - Street 1:65 W HAWK ST
Practice Address - Street 2:
Practice Address - City:HEBER
Practice Address - State:CA
Practice Address - Zip Code:92249-9749
Practice Address - Country:US
Practice Address - Phone:176-033-6942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst