Provider Demographics
NPI:1366810194
Name:DE LA ROSA, TATRA-LI
Entity type:Individual
Prefix:
First Name:TATRA-LI
Middle Name:
Last Name:DE LA ROSA
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 1:576 B ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5269
Mailing Address - Country:US
Mailing Address - Phone:707-536-5069
Mailing Address - Fax:
Practice Address - Street 1:576 B ST STE 2C
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5269
Practice Address - Country:US
Practice Address - Phone:707-536-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83945106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist