Provider Demographics
NPI:1366969891
Name:ROMERO, CARLOS OMAR JR
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:OMAR
Last Name:ROMERO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34443 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4576
Mailing Address - Country:US
Mailing Address - Phone:951-333-7811
Mailing Address - Fax:
Practice Address - Street 1:1905 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3460
Practice Address - Country:US
Practice Address - Phone:909-289-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst