Provider Demographics
NPI:1497879720
Name:WAXMAN, TYLER DEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:DEAN
Last Name:WAXMAN
Suffix:
Gender:M
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:PO BOX 54700
Mailing Address - Street 2:MAILSTOP #2
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0700
Mailing Address - Country:US
Mailing Address - Phone:323-669-2153
Mailing Address - Fax:323-913-3614
Practice Address - Street 1:5000 W SUNSET BLVD
Practice Address - Street 2:SUITE 540M
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5861
Practice Address - Country:US
Practice Address - Phone:323-669-2153
Practice Address - Fax:323-913-3614
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18571103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical