Healthcare Provider Details

I. General information

NPI: 1942793880
Provider Name (Legal Business Name): MARJORIE TAYAG LACAP BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 REDWOOD WAY STE 210
PETALUMA CA
94954-1134
US

IV. Provider business mailing address

1536 9TH ST APT G
ALAMEDA CA
94501-3401
US

V. Phone/Fax

Practice location:
  • Phone: 707-806-9921
  • Fax:
Mailing address:
  • Phone: 650-534-8569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-74576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: