Provider Demographics
NPI:1376608646
Name:BALAKRISHNAN, TANYA LYNN (MPT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:LYNN
Last Name:BALAKRISHNAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:LYNN
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:8131 BILLOWVISTA DR
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7805
Mailing Address - Country:US
Mailing Address - Phone:310-721-2955
Mailing Address - Fax:
Practice Address - Street 1:8131 BILLOWVISTA DR
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-7805
Practice Address - Country:US
Practice Address - Phone:310-721-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist