Healthcare Provider Details

I. General information

NPI: 1053697904
Provider Name (Legal Business Name): WAYNE TASHJIAN MFT, BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15720 VENTURA BLVD SUITE 403
ENCINO CA
91436-2914
US

IV. Provider business mailing address

15720 VENTURA BLVD SUITE 403
ENCINO CA
91436-2914
US

V. Phone/Fax

Practice location:
  • Phone: 818-728-9370
  • Fax: 818-788-3875
Mailing address:
  • Phone: 818-728-9370
  • Fax: 818-788-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC30490
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA# 1-10-7653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: