Healthcare Provider Details

I. General information

NPI: 1861869489
Provider Name (Legal Business Name): SUPATRA HANNA TOVAR PSYD, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E WALNUT ST STE 246
PASADENA CA
91106-5370
US

IV. Provider business mailing address

4000 VIA MARISOL APT 303
LOS ANGELES CA
90042-5153
US

V. Phone/Fax

Practice location:
  • Phone: 626-674-2639
  • Fax:
Mailing address:
  • Phone: 818-636-5343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31949
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86029010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: