Provider Demographics
NPI:1174865737
Name:TALASAZAN, TANNAZ (MA)
Entity Type:Individual
Prefix:MISS
First Name:TANNAZ
Middle Name:
Last Name:TALASAZAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8544 BURTON WAY APT 108
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3388
Mailing Address - Country:US
Mailing Address - Phone:310-500-8629
Mailing Address - Fax:
Practice Address - Street 1:520 S SEPULVEDA BLVD STE 306
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3536
Practice Address - Country:US
Practice Address - Phone:310-943-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist