Healthcare Provider Details

I. General information

NPI: 1053997528
Provider Name (Legal Business Name): NTSIENI TSHIDI MATHALISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131B STONY CIR
SANTA ROSA CA
95401-9507
US

IV. Provider business mailing address

131B STONY CIR
SANTA ROSA CA
95401-9507
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20698
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: