Provider Demographics
NPI:1114375854
Name:TAJ, ATHENA (LMFT)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:TAJ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12986
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92039-2986
Mailing Address - Country:US
Mailing Address - Phone:408-219-8709
Mailing Address - Fax:
Practice Address - Street 1:5190 GOVERNOR DR
Practice Address - Street 2:SUITE #104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2847
Practice Address - Country:US
Practice Address - Phone:408-219-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35036106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist