Healthcare Provider Details

I. General information

NPI: 1750192167
Provider Name (Legal Business Name): CHARITY LEIGH TACBAS AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 W A BARR RD
MOUNT SHASTA CA
96067-9466
US

IV. Provider business mailing address

111 N A ST
MOUNT SHASTA CA
96067-2402
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-5800
  • Fax:
Mailing address:
  • Phone: 530-408-8336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number141220
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: