Healthcare Provider Details

I. General information

NPI: 1790011492
Provider Name (Legal Business Name): MARY CHERUB TAGLE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY MIGUEL M.A.

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W TEMPLE ST
LOS ANGELES CA
90026-4915
US

IV. Provider business mailing address

2121 W TEMPLE ST
LOS ANGELES CA
90026-4915
US

V. Phone/Fax

Practice location:
  • Phone: 213-260-7600
  • Fax:
Mailing address:
  • Phone: 310-984-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number34032
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: