Basic Information
| Provider Information | |||||||||
| NPI: | 1861743189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIZENOR-TATE | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 ANGELES VISTA BLVD. | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232954555 | ||||||||
| FaxNumber: | 3232953021 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 ANGELES VISTA BLVD. | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232954555 | ||||||||
| FaxNumber: | 3232953021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2012 | ||||||||
| LastUpdateDate: | 06/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.