Provider Demographics
NPI:1952172496
Name:MASONIS, TAMARA DANIELLE (SUDRC # 16712)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:DANIELLE
Last Name:MASONIS
Suffix:
Gender:F
Credentials:SUDRC # 16712
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57428 LUPINE DR APT 6
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3877
Mailing Address - Country:US
Mailing Address - Phone:951-290-9945
Mailing Address - Fax:
Practice Address - Street 1:7235 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6724
Practice Address - Country:US
Practice Address - Phone:213-669-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16712171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator