Provider Demographics
NPI:1790011492
Name:TAGLE, MARY CHERUB (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHERUB
Last Name:TAGLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:MIGUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2121 W TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4915
Mailing Address - Country:US
Mailing Address - Phone:310-984-3055
Mailing Address - Fax:
Practice Address - Street 1:2121 W TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4915
Practice Address - Country:US
Practice Address - Phone:213-260-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA34032103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program