Healthcare Provider Details

I. General information

NPI: 1891476289
Provider Name (Legal Business Name): TONYA TANNIAL THEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 SPEERS RD
SANTA ROSA CA
95409-3123
US

IV. Provider business mailing address

1505 MEADOWLARK LN
PETALUMA CA
94954-4465
US

V. Phone/Fax

Practice location:
  • Phone: 707-909-0168
  • Fax:
Mailing address:
  • Phone: 707-971-6265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: