Provider Demographics
NPI:1114375524
Name:TAMAZYAN, DIANE (BA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:TAMAZYAN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 ELDRIDGE AVE
Mailing Address - Street 2:11600 ELDRIDGE AVE
Mailing Address - City:LAKE VIEW TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1716
Mailing Address - Country:US
Mailing Address - Phone:818-686-3000
Mailing Address - Fax:
Practice Address - Street 1:3455 PERCY ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1716
Practice Address - Country:US
Practice Address - Phone:323-268-2100
Practice Address - Fax:323-268-2460
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CAA015740315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA114375524Medicaid