Provider Demographics
NPI:1114667243
Name:ZODULUA, TANYA BATEZA (ACSW)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:BATEZA
Last Name:ZODULUA
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6241 GLADE AVE APT L318
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-0805
Mailing Address - Country:US
Mailing Address - Phone:818-224-0656
Mailing Address - Fax:
Practice Address - Street 1:302 W 5TH ST UNIT 102
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2738
Practice Address - Country:US
Practice Address - Phone:424-570-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW905061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty