Provider Demographics
NPI:1295805133
Name:TAMASSIAN, MIKE (PHD)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:TAMASSIAN
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 1:1101 N PACIFIC AVE
Mailing Address - Street 2:204
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3250
Mailing Address - Country:US
Mailing Address - Phone:818-396-5343
Mailing Address - Fax:
Practice Address - Street 1:1101 N PACIFIC AVE
Practice Address - Street 2:204
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3250
Practice Address - Country:US
Practice Address - Phone:818-396-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19694103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00CP196940Medicaid
CACP19694Medicare ID - Type Unspecified