Provider Demographics
NPI:1104920230
Name:ALTA-GRACE L TAN, PSY D PSYCHOLOGICAL SERVICES, INC
Entity type:Organization
Organization Name:ALTA-GRACE L TAN, PSY D PSYCHOLOGICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALTA-GRACE
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:818-523-1809
Mailing Address - Street 1:18546 ROSCOE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-5454
Mailing Address - Country:US
Mailing Address - Phone:818-886-5628
Mailing Address - Fax:
Practice Address - Street 1:18546 ROSCOE BLVD
Practice Address - Street 2:STE 210
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-5454
Practice Address - Country:US
Practice Address - Phone:818-886-5628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18653103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18678Medicare PIN