Provider Demographics
NPI:1902016140
Name:WIDISS, TANYA (RD, MFT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:WIDISS
Suffix:
Gender:F
Credentials:RD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 E. HUNTINGTON DRIVE
Mailing Address - Street 2:#333
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-6204
Mailing Address - Country:US
Mailing Address - Phone:626-353-0492
Mailing Address - Fax:626-445-6818
Practice Address - Street 1:444 E. HUNTINGTON DRIVE
Practice Address - Street 2:#333
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-6204
Practice Address - Country:US
Practice Address - Phone:626-447-0247
Practice Address - Fax:626-447-1443
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23731106H00000X
133V00000X
R366197133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered