Healthcare Provider Details

I. General information

NPI: 1356800155
Provider Name (Legal Business Name): TIFFANY ROSE TACHIQUIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ESTUDILLO AVE STE 100
SAN LEANDRO CA
94577-4962
US

IV. Provider business mailing address

400 ESTUDILLO AVE STE 100
SAN LEANDRO CA
94577-4962
US

V. Phone/Fax

Practice location:
  • Phone: 510-924-0548
  • Fax:
Mailing address:
  • Phone: 510-924-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT162073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: