Provider Demographics
NPI:1649683285
Name:TANGEMAN, MICHELLE (LMFT, BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TANGEMAN
Suffix:
Gender:F
Credentials:LMFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28649 S WESTERN AVE UNIT 6516
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90734-0109
Mailing Address - Country:US
Mailing Address - Phone:213-357-2774
Mailing Address - Fax:
Practice Address - Street 1:6101 W CENTINELA AVE
Practice Address - Street 2:SUITE 380
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6337
Practice Address - Country:US
Practice Address - Phone:805-428-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-15144103K00000X
CAMFC85890106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC85890OtherBBS