Provider Demographics
NPI:1639518939
Name:LIQUIDANO, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LIQUIDANO
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:PO BOX 29371
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-0371
Mailing Address - Country:US
Mailing Address - Phone:310-668-3423
Mailing Address - Fax:310-668-3452
Practice Address - Street 1:1720 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3052
Practice Address - Country:US
Practice Address - Phone:310-668-4272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 225400000X
CAASW 64525101YM0800X, 104100000X
CALCSW886801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner