Provider Demographics
NPI:1629941133
Name:HARSTAD, EVE K
Entity type:Individual
Prefix:
First Name:EVE
Middle Name:K
Last Name:HARSTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5223
Mailing Address - Country:US
Mailing Address - Phone:707-331-2010
Mailing Address - Fax:
Practice Address - Street 1:983 SONOMA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4818
Practice Address - Country:US
Practice Address - Phone:707-575-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-VTILFU175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty