Provider Demographics
NPI:1104239045
Name:TOMEVI, CHARLOTTE
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:TOMEVI
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 1:17 KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEDALE
Mailing Address - State:ID
Mailing Address - Zip Code:83628-3417
Mailing Address - Country:US
Mailing Address - Phone:208-741-3838
Mailing Address - Fax:208-498-2026
Practice Address - Street 1:17 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:HOMEDALE
Practice Address - State:ID
Practice Address - Zip Code:83628-3417
Practice Address - Country:US
Practice Address - Phone:208-741-3838
Practice Address - Fax:208-498-2026
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1-17-26141103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty