Provider Demographics
NPI:1144413725
Name:BANI-TABA, FATEMEH AHDI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:FATEMEH
Middle Name:AHDI
Last Name:BANI-TABA
Suffix:
Gender:F
Credentials:PSYD
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 6747
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95406-0747
Mailing Address - Country:US
Mailing Address - Phone:707-571-5181
Mailing Address - Fax:707-571-4110
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:MOB EAST
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-571-5181
Practice Address - Fax:707-571-4110
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18968103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical