Provider Demographics
NPI:1336819564
Name:LA TANYA TAKLA, PSYCHOLOGIST INC
Entity type:Organization
Organization Name:LA TANYA TAKLA, PSYCHOLOGIST INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSE CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LA TANYA
Authorized Official - Middle Name:ALICIA
Authorized Official - Last Name:TAKLA
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:916-642-9522
Mailing Address - Street 1:1343 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5249
Mailing Address - Country:US
Mailing Address - Phone:916-642-9522
Mailing Address - Fax:
Practice Address - Street 1:1651 RESPONSE RD STE 111
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-5254
Practice Address - Country:US
Practice Address - Phone:916-642-9522
Practice Address - Fax:916-678-4138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-19
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100224781Medicaid
CACA460451Medicaid