Healthcare Provider Details

I. General information

NPI: 1023617875
Provider Name (Legal Business Name): TANYA HAUGHAWOUT CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 BRISTOL ST STE 200
COSTA MESA CA
92626-8607
US

IV. Provider business mailing address

16412 RHONE LN
HUNTINGTON BEACH CA
92647-4129
US

V. Phone/Fax

Practice location:
  • Phone: 714-424-9001
  • Fax:
Mailing address:
  • Phone: 805-304-2701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number42775
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: