Provider Demographics
NPI:1912042375
Name:ROBERTS, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:ROBERTS
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:PO BOX 6025
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-6025
Mailing Address - Country:US
Mailing Address - Phone:209-401-2134
Mailing Address - Fax:
Practice Address - Street 1:404 W PINE ST STE 1
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-2048
Practice Address - Country:US
Practice Address - Phone:209-401-2134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20414101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10969254OtherCAQH
CA10969254OtherCAQH