Provider Demographics
NPI:1316340722
Name:TAVANGAR, RASA
Entity type:Individual
Prefix:
First Name:RASA
Middle Name:
Last Name:TAVANGAR
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 1:600 CELESTE WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-9720
Mailing Address - Country:US
Mailing Address - Phone:831-251-3372
Mailing Address - Fax:
Practice Address - Street 1:104 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3900
Practice Address - Country:US
Practice Address - Phone:831-423-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF #68415106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist