Provider Demographics
NPI:1497895197
Name:TIZNADO, MONICA MICHELLE
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:MICHELLE
Last Name:TIZNADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4820
Mailing Address - Country:US
Mailing Address - Phone:310-390-6612
Mailing Address - Fax:310-398-5690
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-846-2100
Practice Address - Fax:310-846-2139
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81074106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist