Provider Demographics
NPI:1861637589
Name:GITTELSON, MYAH TARNOW (PSYD)
Entity type:Individual
Prefix:
First Name:MYAH
Middle Name:TARNOW
Last Name:GITTELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 LAUREL CANYON BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3998
Mailing Address - Country:US
Mailing Address - Phone:818-538-4112
Mailing Address - Fax:
Practice Address - Street 1:4705 LAUREL CANYON BLVD STE 204
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3998
Practice Address - Country:US
Practice Address - Phone:818-538-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102803 PROVISIONAL103T00000X
CAPSY24388103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist