Provider Demographics
NPI:1619504073
Name:DEL REAL, TAYRA
Entity Type:Individual
Prefix:
First Name:TAYRA
Middle Name:
Last Name:DEL REAL
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 1:325 S SAN DIMAS CANYON RD APT 13B
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3046
Mailing Address - Country:US
Mailing Address - Phone:626-222-3327
Mailing Address - Fax:
Practice Address - Street 1:325 S SAN DIMAS CANYON RD APT 13B
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3046
Practice Address - Country:US
Practice Address - Phone:626-222-3327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13771-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)