Provider Demographics
NPI:1366777906
Name:TATE DE LARA, ASHLEY MELISSA (PSYD)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MELISSA
Last Name:TATE DE LARA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HARRISON ST, 7TH FL
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-4101
Mailing Address - Fax:877-738-4262
Practice Address - Street 1:650 N WINCHESTER BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1511
Practice Address - Country:US
Practice Address - Phone:650-271-4621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23064103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical