Provider Demographics
NPI:1942383088
Name:CORRAL, ILDIKO TABORI (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILDIKO
Middle Name:TABORI
Last Name:CORRAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ILDIKO
Other - Middle Name:LESLIE
Other - Last Name:TABORI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1850 SAWTELLE BLVD
Mailing Address - Street 2:LOS ANGELES
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7084
Mailing Address - Country:US
Mailing Address - Phone:310-429-5968
Mailing Address - Fax:310-558-9098
Practice Address - Street 1:1850 SAWTELLE BLVD
Practice Address - Street 2:LOS ANGELES
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7084
Practice Address - Country:US
Practice Address - Phone:310-429-5968
Practice Address - Fax:310-558-9098
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19688103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY196880Medicaid
CAPSY196880OtherMEDI-CAL
CACP19688Medicare PIN