MEDICARE: DEPARTMENT OF HEALTH SERVICES

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1376757989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEPARTMENT OF HEALTH SERVICES

Provider Business Mailing Address
First Line	:	7425 RANCHO LOS GUILICOS RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-6519
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7425 RANCHO LOS GUILICOS RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-6519
Country	:	US
Telephone Number	:	707-565-4700
Fax Number	:

Authorized Official
Title or Position	:	COMPLIANCE AUDITOR ACCOUNTANT III
Name	:	DIANA STORNETTA
Credential	:
Telephone Number	:	707-565-4782

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	08/22/2020

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Directions to “DEPARTMENT OF HEALTH SERVICES ” Practice Location

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