Provider Demographics
NPI:1356058416
Name:WEBSTER, TALIA LEIGH
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:LEIGH
Last Name:WEBSTER
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 1:22471 ASPAN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 S TUSTIN ST BLDG D
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2550
Practice Address - Country:US
Practice Address - Phone:714-289-3936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136569106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty