Provider Demographics
NPI:1962532176
Name:TANGNER, CRAIG MARCELLUS (MA,MED, MFT INTERN)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:MARCELLUS
Last Name:TANGNER
Suffix:
Gender:M
Credentials:MA,MED, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 ALAMO ST STE F
Mailing Address - Street 2:SUITE 2032
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2110
Mailing Address - Country:US
Mailing Address - Phone:805-577-1418
Mailing Address - Fax:
Practice Address - Street 1:1182 TIVOLI LN
Practice Address - Street 2:UNIT 194
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-0926
Practice Address - Country:US
Practice Address - Phone:805-577-1418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45848106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist