Healthcare Provider Details

I. General information

NPI: 1659080695
Provider Name (Legal Business Name): HASMIG TATIOSSIAN ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

IV. Provider business mailing address

PO BOX 1347
ROHNERT PARK CA
94927-1347
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-6900
  • Fax:
Mailing address:
  • Phone: 818-730-8130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number125498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: