Provider Demographics
NPI:1417095548
Name:TANNENWALD, LAURA E (MFT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:E
Last Name:TANNENWALD
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51904
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-0739
Mailing Address - Country:US
Mailing Address - Phone:619-857-6332
Mailing Address - Fax:
Practice Address - Street 1:4546 EL CAMINO REAL STE 235
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1041
Practice Address - Country:US
Practice Address - Phone:619-857-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33555106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist