Provider Demographics
NPI:1962001230
Name:MACLEOD, TANYA GEANNA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:GEANNA
Last Name:MACLEOD
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 1:474 WEST VERMONT AVE. STE,. 101
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025
Mailing Address - Country:US
Mailing Address - Phone:760-480-2255
Mailing Address - Fax:760-888-8339
Practice Address - Street 1:474 WEST VERMONT AVE., STE., 101
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-480-2255
Practice Address - Fax:760-888-8339
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CAMPSS-SLPGXB175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist