Provider Demographics
NPI:1548944382
Name:TAN, GINIENA (LEP, PPS)
Entity type:Individual
Prefix:MRS
First Name:GINIENA
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:LEP, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 ENCINITAS BLVD. STE. 108
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:858-245-0704
Mailing Address - Fax:
Practice Address - Street 1:2235 ENCINITAS BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-4356
Practice Address - Country:US
Practice Address - Phone:760-704-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
CA4046103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool