Provider Demographics
NPI:1659686772
Name:DEIRMENDJIAN, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:DEIRMENDJIAN
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:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:VERDUGO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91046-0330
Mailing Address - Country:US
Mailing Address - Phone:818-539-7112
Mailing Address - Fax:
Practice Address - Street 1:402 W BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3542
Practice Address - Country:US
Practice Address - Phone:818-539-7112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA127213106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner