Basic Information
| Provider Information | |||||||||
| NPI: | 1114575784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAFOLLA RIOS | ||||||||
| FirstName: | ANA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6090 REDWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949454569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154481500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6090 REDWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949454569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154481500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2019 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 228106 | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 228106 | 01 | CA | CALIFORNIA BOARD OF BEHAVIORAL SCIENCES | OTHER |