Provider Demographics
NPI:1073167458
Name:TABARES, ROSARIO (AMFT)
Entity Type:Individual
Prefix:
First Name:ROSARIO
Middle Name:
Last Name:TABARES
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4173 INGLEWOOD BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066
Mailing Address - Country:US
Mailing Address - Phone:310-313-7652
Mailing Address - Fax:
Practice Address - Street 1:4173 INGLEWOOD BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066
Practice Address - Country:US
Practice Address - Phone:310-313-7652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA119950106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program