Provider Demographics
NPI:1023617875
Name:HAUGHAWOUT, TANYA (CMT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:HAUGHAWOUT
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16412 RHONE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-4129
Mailing Address - Country:US
Mailing Address - Phone:805-304-2701
Mailing Address - Fax:
Practice Address - Street 1:1202 BRISTOL ST STE 200
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-8607
Practice Address - Country:US
Practice Address - Phone:714-424-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist