Provider Demographics
NPI:1376007641
Name:MUSHONGA, TANDIWE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TANDIWE
Middle Name:
Last Name:MUSHONGA
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 1:621 S VIRGIL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-4027
Mailing Address - Country:US
Mailing Address - Phone:213-368-5401
Mailing Address - Fax:
Practice Address - Street 1:621 S VIRGIL AVE STE 300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-4027
Practice Address - Country:US
Practice Address - Phone:213-368-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATBD103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical