Basic Information
| Provider Information | |||||||||
| NPI: | 1053868059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEANGELIS | ||||||||
| FirstName: | TAMARA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6055 E WASHINGTON BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900402449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233460960 | ||||||||
| FaxNumber: | 3233460966 | ||||||||
| Practice Location | |||||||||
| Address1: | 6055 E WASHINGTON BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900402449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233460960 | ||||||||
| FaxNumber: | 3233460966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2016 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/29/2021 | ||||||||
| NPIReactivationDate: | 08/25/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 1041C0700X | 100232 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.