Provider Demographics
NPI:1861869489
Name:TOVAR, SUPATRA HANNA (PSYD, RD)
Entity type:Individual
Prefix:DR
First Name:SUPATRA
Middle Name:HANNA
Last Name:TOVAR
Suffix:
Gender:F
Credentials:PSYD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 VIA MARISOL APT 303
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-5153
Mailing Address - Country:US
Mailing Address - Phone:818-636-5343
Mailing Address - Fax:
Practice Address - Street 1:1000 E WALNUT ST STE 246
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-5370
Practice Address - Country:US
Practice Address - Phone:626-674-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86029010133V00000X
390200000X
CAPSY31949103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86029010OtherCDR RD CREDENTIAL