Provider Demographics
NPI:1548978463
Name:TAVITIAN, VICTORIA A
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:TAVITIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S 6TH ST APT 110
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-3102
Mailing Address - Country:US
Mailing Address - Phone:818-748-5890
Mailing Address - Fax:
Practice Address - Street 1:4849 RONSON CT STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1805
Practice Address - Country:US
Practice Address - Phone:844-737-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133912106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty