Provider Demographics
NPI:1336467919
Name:MALLAN, TANYA (TANYA MALLAN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MALLAN
Suffix:
Gender:F
Credentials:TANYA MALLAN
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:MALLAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:5289 JOAQUIN RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-2843
Mailing Address - Country:US
Mailing Address - Phone:707-538-8092
Mailing Address - Fax:
Practice Address - Street 1:5289 JOAQUIN RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-2843
Practice Address - Country:US
Practice Address - Phone:707-477-0434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10037235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist