Basic Information
| Provider Information | |||||||||
| NPI: | 1578735650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKIBBIN | ||||||||
| FirstName: | TAMA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 CLEVELAND AVE, #B | ||||||||
| Address2: | SANTA ROSA TREATMENT PROGRAM | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075760818 | ||||||||
| FaxNumber: | 7075767845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 CLEVELAND AVE, #B | ||||||||
| Address2: | SANTA ROSA TREATMENT PROGRAM | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075760818 | ||||||||
| FaxNumber: | 7075767845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2008 | ||||||||
| LastUpdateDate: | 08/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | RI-M1301282236 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.