MEDICARE: TAMANTHA BOYCHUK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	26154	CA

General Provider Information

NPI Number	:	1457630154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMANTHA BOYCHUK LCSW

Provider Business Mailing Address
First Line	:	1253 LOUDEN LN
Second Line	:
City	:	IMPERIAL BEACH
State	:	CA
Zip	:	91932-3240
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2534 STATE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1316
Country	:	US
Telephone Number	:	619-516-8100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/11/2011

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