Healthcare Provider Details

I. General information

NPI: 1326591942
Provider Name (Legal Business Name): THALIA SUZANNE TROTTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2016
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2447 SUMMERFIELD RD
SANTA ROSA CA
95405-7815
US

IV. Provider business mailing address

55 MARIA DR APT 525
PETALUMA CA
94954-3561
US

V. Phone/Fax

Practice location:
  • Phone: 707-544-3299
  • Fax:
Mailing address:
  • Phone: 516-816-4509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number101676
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberF5052808
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: