Provider Demographics
NPI:1578735650
Name:MCKIBBIN, TAMA MARIE
Entity Type:Individual
Prefix:
First Name:TAMA
Middle Name:MARIE
Last Name:MCKIBBIN
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 1:1901 CLEVELAND AVE, #B
Mailing Address - Street 2:SANTA ROSA TREATMENT PROGRAM
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401
Mailing Address - Country:US
Mailing Address - Phone:707-576-0818
Mailing Address - Fax:707-576-7845
Practice Address - Street 1:1901 CLEVELAND AVE, #B
Practice Address - Street 2:SANTA ROSA TREATMENT PROGRAM
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:707-576-0818
Practice Address - Fax:707-576-7845
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CARI-M1301282236101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)