Provider Demographics
NPI:1629585724
Name:VIRGEN, TANIA (RBT)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:VIRGEN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CIVIC CENTER DR STE 207
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-6039
Mailing Address - Country:US
Mailing Address - Phone:760-659-6574
Mailing Address - Fax:
Practice Address - Street 1:110 CIVIC CENTER DR STE 207
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6039
Practice Address - Country:US
Practice Address - Phone:760-659-6574
Practice Address - Fax:760-659-6574
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-17-39588106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician