MEDICARE: ALEXANDRA TANNER PHD

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	103T00000X	Psychologist	PSY34509	CA
2	103TC0700X	Clinical Psychologist	PSY34509	CA

General Provider Information

NPI Number	:	1942087861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA TANNER PHD

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	760 WESTWOOD PLZ STE C8-749
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-3803
Country	:	US
Telephone Number	:	323-205-6843
Fax Number	:

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

Provider Enumeration Date	:	09/13/2023
Last Update Date	:	04/01/2025

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