Provider Demographics
NPI:1295839322
Name:TAN, ALTA-GRACE L (PSYD)
Entity Type:Individual
Prefix:
First Name:ALTA-GRACE
Middle Name:L
Last Name:TAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17075 DEVONSHIRE STREET
Mailing Address - Street 2:STE 204
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5408
Mailing Address - Country:US
Mailing Address - Phone:818-368-8929
Mailing Address - Fax:818-368-8940
Practice Address - Street 1:17075 DEVONSHIRE STREET
Practice Address - Street 2:STE 204
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5408
Practice Address - Country:US
Practice Address - Phone:818-368-8929
Practice Address - Fax:818-368-8940
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18653103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP18653BMedicare PIN