Provider Demographics
NPI:1851468706
Name:TANAKA, MARY A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:TANAKA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:TANAKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1925 DALY STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-3309
Mailing Address - Country:US
Mailing Address - Phone:323-226-4447
Mailing Address - Fax:323-223-8380
Practice Address - Street 1:1925 DALY ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-3309
Practice Address - Country:US
Practice Address - Phone:323-226-4447
Practice Address - Fax:323-223-8380
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS99671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical