MEDICARE: LOMI SCHOOL FOUNDATION

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	101YM0800X	Mental Health Counselor	306494090	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61-31568	OTHER	CA	UNITED HEALTHCARE SERVICE

General Provider Information

NPI Number	:	1437171543
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOMI SCHOOL FOUNDATION

Provider Business Mailing Address
First Line	:	320 10TH ST STE 200
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-5291
Country	:	US
Telephone Number	:	707-579-0465
Fax Number	:	707-579-0560

Provider Business Practice Location Address
First Line	:	320 10TH ST STE 200
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-5291
Country	:	US
Telephone Number	:	707-579-0465
Fax Number	:	707-579-0560

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	MS. SHANNON D. SWEENEY
Credential	:
Telephone Number	:	707-579-0465

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	01/12/2023

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1134329188 — MS. RACHEL ELIZABETH, LEVINE HONEY MFT
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1306022710 — MS. VICTORIA MAXINE STEFANI MFT
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1477700938 — MR. JUSTIN DAVID FORMAN B.S.
Practice Location Address:

320 10TH ST , STE 200
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95401-5291

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1457506305 — MR. PATRICK S ENNIS LCSW
Practice Location Address:

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1336452853 — CHERYL L NYGARD
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Directions to “LOMI SCHOOL FOUNDATION ” Practice Location

Language	Start Address	Practice Location

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