Provider Demographics
NPI:1306977632
Name:DE TAR, LOIS ANITA (MFT)
Entity type:Individual
Prefix:MS
First Name:LOIS
Middle Name:ANITA
Last Name:DE TAR
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:CLARE
Other - Middle Name:
Other - Last Name:DE TAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:17316 FORT TEJON RD
Mailing Address - Street 2:
Mailing Address - City:LLANO
Mailing Address - State:CA
Mailing Address - Zip Code:93544-1300
Mailing Address - Country:US
Mailing Address - Phone:661-944-9023
Mailing Address - Fax:
Practice Address - Street 1:190 SIERRA CT STE C8
Practice Address - Street 2:PENNY LANE
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7609
Practice Address - Country:US
Practice Address - Phone:661-266-4783
Practice Address - Fax:661-266-1210
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42339106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist