Provider Demographics
NPI:1366635526
Name:TAKLA, LA TANYA ALICIA (EDD, LMFT, LPCC)
Entity Type:Individual
Prefix:DR
First Name:LA TANYA
Middle Name:ALICIA
Last Name:TAKLA
Suffix:
Gender:F
Credentials:EDD, LMFT, LPCC
Other - Prefix:MRS
Other - First Name:LA TANYA
Other - Middle Name:ALICIA
Other - Last Name:TRAILER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1343 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5249
Mailing Address - Country:US
Mailing Address - Phone:916-827-3058
Mailing Address - Fax:916-678-4138
Practice Address - Street 1:3705 HAVEN AVE STE 112
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-1011
Practice Address - Country:US
Practice Address - Phone:916-827-3058
Practice Address - Fax:916-678-4138
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32391103TC0700X
CA49566106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA460541Medicaid