Provider Demographics
NPI:1629381561
Name:TARAVELLA, JOSEPH R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:TARAVELLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 NATIONAL BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4141
Mailing Address - Country:US
Mailing Address - Phone:917-865-0572
Mailing Address - Fax:
Practice Address - Street 1:10801 NATIONAL BLVD STE 240
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4141
Practice Address - Country:US
Practice Address - Phone:917-865-0572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016241103TC0700X
CAPSY30856103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical