MEDICARE: TIAMAT TREATMENT CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1104783638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIAMAT TREATMENT CENTER LLC

Provider Business Mailing Address
First Line	:	3022 INTERNATIONAL BLVD STE 410
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94601-2229
Country	:	US
Telephone Number	:	510-813-5939
Fax Number	:

Provider Business Practice Location Address
First Line	:	3022 INTERNATIONAL BLVD STE 410
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94601-2229
Country	:	US
Telephone Number	:	510-813-5939
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DONNA EDWARDS
Credential	:	CAADE
Telephone Number	:	510-813-5939

Provider Enumeration Date	:	01/07/2026
Last Update Date	:	01/07/2026

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