Provider Demographics
NPI:1669840328
Name:DISTILLER, NATASHA (MA (PSYCHOLOGY); PHD)
Entity Type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:
Last Name:DISTILLER
Suffix:
Gender:F
Credentials:MA (PSYCHOLOGY); PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4554 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-2010
Mailing Address - Country:US
Mailing Address - Phone:415-484-5561
Mailing Address - Fax:
Practice Address - Street 1:4554 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-2010
Practice Address - Country:US
Practice Address - Phone:415-484-5561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF85514106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist