Healthcare Provider Details

I. General information

NPI: 1740321199
Provider Name (Legal Business Name): TARA MARIE NYASIO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 E 7TH STREET (06/116B)
LONG BEACH CA
90822
US

IV. Provider business mailing address

5901 E 7TH STREET (06/116B)
LONG BEACH CA
90822
US

V. Phone/Fax

Practice location:
  • Phone: 714-434-4691
  • Fax:
Mailing address:
  • Phone: 714-434-4691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY25392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: