Provider Demographics
NPI:1588082911
Name:MALLON, TISHA (LAC, DIPLAC)
Entity type:Individual
Prefix:PROF
First Name:TISHA
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:LAC, DIPLAC
Other - Prefix:MS
Other - First Name:TISHA
Other - Middle Name:
Other - Last Name:MALLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC, DIPLAC
Mailing Address - Street 1:56 BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1727
Mailing Address - Country:US
Mailing Address - Phone:415-378-3039
Mailing Address - Fax:
Practice Address - Street 1:21 TAMAL VISTA BLVD
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1130
Practice Address - Country:US
Practice Address - Phone:415-378-3039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 4302171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist