Healthcare Provider Details

I. General information

NPI: 1215089701
Provider Name (Legal Business Name): NOA TIDHAR BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W 10TH ST
ANTIOCH CA
94509-1653
US

IV. Provider business mailing address

1721 ELM ST
EL CERRITO CA
94530-1908
US

V. Phone/Fax

Practice location:
  • Phone: 925-777-9540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: