Provider Demographics
NPI:1568806172
Name:SHTUTMAN, TATYANA (MA)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:SHTUTMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 VAN BUREN AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4946
Mailing Address - Country:US
Mailing Address - Phone:530-902-5085
Mailing Address - Fax:
Practice Address - Street 1:2550 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3406
Practice Address - Country:US
Practice Address - Phone:626-463-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health