Provider Demographics
NPI:1942459144
Name:PERIS, TARA SOPHIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:SOPHIA
Last Name:PERIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4305
Mailing Address - Country:US
Mailing Address - Phone:310-804-2141
Mailing Address - Fax:
Practice Address - Street 1:10850 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4305
Practice Address - Country:US
Practice Address - Phone:310-804-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY220710Medicaid
CAEC214ZMedicare PIN