Provider Demographics
NPI:1265596134
Name:VAISMAN-TZACHOR, REUBEN (PHD)
Entity type:Individual
Prefix:DR
First Name:REUBEN
Middle Name:
Last Name:VAISMAN-TZACHOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 BARRY AVE 112
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4090
Mailing Address - Country:US
Mailing Address - Phone:310-477-6000
Mailing Address - Fax:
Practice Address - Street 1:3111 BROADWAY D
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4278
Practice Address - Country:US
Practice Address - Phone:213-369-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15091103G00000X, 103TA0400X, 103TA0700X, 103TC0700X, 103TC1900X, 103TC2200X, 103TE1100X, 103TF0000X, 103TF0200X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PHD0000OtherBLUE SHIELD OF CALIFORNIA
CAC CP15091OtherUN ITED AMERICAN INSURANC
CA00CA98888OtherBLUE SHIELD PROVIDER NUMB
CAC CP15091OtherUN ITED AMERICAN INSURANC