Provider Demographics
NPI:1528142148
Name:VICTOR, TARA L (PHD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:VICTOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 SCHADER DR
Mailing Address - Street 2:107
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2946
Mailing Address - Country:US
Mailing Address - Phone:310-478-3711
Mailing Address - Fax:310-268-4935
Practice Address - Street 1:760 WESTWOOD PLAZA
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8353
Practice Address - Country:US
Practice Address - Phone:310-825-9989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21150103G00000X
CAPSY 21150103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABJ876ZMedicare PIN