Provider Demographics
NPI:1568765725
Name:TANTER, KHALILAH (RRW)
Entity Type:Individual
Prefix:MISS
First Name:KHALILAH
Middle Name:
Last Name:TANTER
Suffix:
Gender:F
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 E ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3210
Mailing Address - Country:US
Mailing Address - Phone:562-597-5300
Mailing Address - Fax:562-597-5300
Practice Address - Street 1:4801 E ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3210
Practice Address - Country:US
Practice Address - Phone:562-597-5300
Practice Address - Fax:562-597-5300
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10642101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)