Provider Demographics
NPI:1861743189
Name:TIZENOR-TATE, DONNA M
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:M
Last Name:TIZENOR-TATE
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 1:5300 ANGELES VISTA BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043
Mailing Address - Country:US
Mailing Address - Phone:323-295-4555
Mailing Address - Fax:323-295-3021
Practice Address - Street 1:5300 ANGELES VISTA BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043
Practice Address - Country:US
Practice Address - Phone:323-295-4555
Practice Address - Fax:323-295-3021
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health