Provider Demographics
NPI:1891399531
Name:TAN, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:TAN
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 1:1055 E COLORADO BLVD STE 560
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2380
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:17848 SKY PARK CIR STE B
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6135
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-21-51064103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician