Healthcare Provider Details

I. General information

NPI: 1255813762
Provider Name (Legal Business Name): KRISTA BASILE TABUENCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UCLA MEDICAL PLZ STE 1100
LOS ANGELES CA
90095-8549
US

IV. Provider business mailing address

5767 W CENTURY BLVD
LOS ANGELES CA
90095-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9989
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34041
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPSY34041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: