Healthcare Provider Details

I. General information

NPI: 1528738986
Provider Name (Legal Business Name): TAYSIA DE MESA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

IV. Provider business mailing address

1328 W MANCHESTER AVE
LOS ANGELES CA
90044-2240
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-6612
  • Fax: 310-398-5690
Mailing address:
  • Phone: 323-778-9593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: