Provider Demographics
NPI:1699161232
Name:OSSIPOFF, TANYA (LMFT INTERN)
Entity type:Individual
Prefix:MS
First Name:TANYA
Middle Name:
Last Name:OSSIPOFF
Suffix:
Gender:F
Credentials:LMFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-0591
Mailing Address - Country:US
Mailing Address - Phone:831-566-9110
Mailing Address - Fax:
Practice Address - Street 1:6233 SOQUEL DR STE C
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3184
Practice Address - Country:US
Practice Address - Phone:831-239-9406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF78526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist