Provider Demographics
NPI:1093356586
Name:ATEYEH, TALA
Entity type:Individual
Prefix:
First Name:TALA
Middle Name:
Last Name:ATEYEH
Suffix:
Gender:F
Credentials:
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 5282
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94083-5282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 BRADFORD ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1727
Practice Address - Country:US
Practice Address - Phone:650-482-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-05
Last Update Date:2025-01-07
Deactivation Date:2024-10-31
Deactivation Code:
Reactivation Date:2024-11-14
Provider Licenses
StateLicense IDTaxonomies
CA15921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health