Healthcare Provider Details

I. General information

NPI: 1619753290
Provider Name (Legal Business Name): HANNA VANESSA TANNENBAUM PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 04/25/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 HOLIDAY CT STE 201
LA JOLLA CA
92037-1808
US

IV. Provider business mailing address

135 LIVERPOOL DR STE A, PO BOX 114
ENCINITAS CA
92024-5107
US

V. Phone/Fax

Practice location:
  • Phone: 858-371-3737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35786
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: