Provider Demographics
NPI:1124230859
Name:TISDALE, LE ANN (MFT)
Entity Type:Individual
Prefix:
First Name:LE
Middle Name:ANN
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:LE
Other - Middle Name:ANN
Other - Last Name:TISDALE-PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1777 HAMILTON AVE
Mailing Address - Street 2:STE 212
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5430
Mailing Address - Country:US
Mailing Address - Phone:408-266-5800
Mailing Address - Fax:408-266-5809
Practice Address - Street 1:1777 HAMILTON AVE
Practice Address - Street 2:STE 212
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5430
Practice Address - Country:US
Practice Address - Phone:408-266-5800
Practice Address - Fax:408-266-5809
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19817106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist