Provider Demographics
NPI:1922294206
Name:DISSELKOEN, TANYA
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:
Last Name:DISSELKOEN
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 1:10717 CAMINO RUIZ
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2360
Mailing Address - Country:US
Mailing Address - Phone:858-695-2211
Mailing Address - Fax:858-695-3521
Practice Address - Street 1:10717 CAMINO RUIZ
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2360
Practice Address - Country:US
Practice Address - Phone:858-695-2211
Practice Address - Fax:858-695-3521
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health