Healthcare Provider Details

I. General information

NPI: 1003605023
Provider Name (Legal Business Name): TYIANNA MARIE PETITHOMME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 09/15/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 LOS ALAMITOS
LOS ALAMITOS CA
90720
US

IV. Provider business mailing address

119 W TORRANCE BLVD STE 100
REDONDO BEACH CA
90277-3600
US

V. Phone/Fax

Practice location:
  • Phone: 925-482-3334
  • Fax:
Mailing address:
  • Phone: 310-374-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: