Provider Demographics
NPI:1194031328
Name:SAMOLE, TRISTA JEAN (MS)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:JEAN
Last Name:SAMOLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 MCBRIDE LN APT 76
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2964
Mailing Address - Country:US
Mailing Address - Phone:720-987-9426
Mailing Address - Fax:
Practice Address - Street 1:1360 N DUTTON AVE STE C
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4668
Practice Address - Country:US
Practice Address - Phone:707-569-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor