Provider Demographics
NPI:1659336204
Name:MESIROW, TANYA (PHD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MESIROW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28999 OLD TOWN FRONT ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5805
Mailing Address - Country:US
Mailing Address - Phone:951-775-4057
Mailing Address - Fax:951-302-9235
Practice Address - Street 1:28999 OLD TOWN FRONT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5805
Practice Address - Country:US
Practice Address - Phone:951-775-4057
Practice Address - Fax:951-302-9235
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17044103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL170440Medicare ID - Type Unspecified