Provider Demographics
NPI:1700106259
Name:FISCHETTI, TARA LENEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:LENEE
Last Name:FISCHETTI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:LENEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 25722
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-0722
Mailing Address - Country:US
Mailing Address - Phone:310-460-8438
Mailing Address - Fax:
Practice Address - Street 1:1081 WESTWOOD BLVD
Practice Address - Street 2:SUITE # 221
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2911
Practice Address - Country:US
Practice Address - Phone:310-460-8438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21702103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical