Basic Information
| Provider Information | |||||||||
| NPI: | 1013108950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAO | ||||||||
| FirstName: | TISE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18043 | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902094043 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12669 ENCINITAS AVE | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913423635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007008705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 54086 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.