Basic Information
| Provider Information | |||||||||
| NPI: | 1306977632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE TAR | ||||||||
| FirstName: | LOIS | ||||||||
| MiddleName: | ANITA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DE TAR | ||||||||
| OtherFirstName: | CLARE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17316 FORT TEJON RD | ||||||||
| Address2: | |||||||||
| City: | LLANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935441300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619449023 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 190 SIERRA CT STE C8 | ||||||||
| Address2: | PENNY LANE | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935507609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612664783 | ||||||||
| FaxNumber: | 6612661210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 42339 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.