Basic Information
| Provider Information | |||||||||
| NPI: | 1528142148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VICTOR | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2308 SCHADER DR | ||||||||
| Address2: | 107 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
| FaxNumber: | 3102684935 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 WESTWOOD PLAZA | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900958353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/24/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY21150 | CA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | PSY 21150 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.