Healthcare Provider Details

I. General information

NPI: 1457069551
Provider Name (Legal Business Name): T'ANNA IRVINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 CRENSHAW BLVD
LOS ANGELES CA
90008-1821
US

IV. Provider business mailing address

3850 CRENSHAW BLVD
LOS ANGELES CA
90008-1821
US

V. Phone/Fax

Practice location:
  • Phone: 323-593-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: