Basic Information
Provider Information | |||||||||
NPI: | 1326708462 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEHOLLANDER | ||||||||
FirstName: | TANYA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2550 N HOLLYWOOD WAY STE 102 | ||||||||
Address2: |   | ||||||||
City: | BURBANK | ||||||||
State: | CA | ||||||||
PostalCode: | 915055031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8667278274 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1040 N 10TH ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490096150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8442631613 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2021 | ||||||||
LastUpdateDate: | 12/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | Y |   |   |   |   |
No ID Information.