Healthcare Provider Details

I. General information

NPI: 1629527460
Provider Name (Legal Business Name): CHRISTINE K TA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date: 08/20/2018
Reactivation Date: 08/29/2018

III. Provider practice location address

1301 PINE AVE
LONG BEACH CA
90813
US

IV. Provider business mailing address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-1159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY33562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: