Healthcare Provider Details

I. General information

NPI: 1669603320
Provider Name (Legal Business Name): JOHN E. ROE, PH.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 CAMERON PARK DR SUITE 301
CAMERON PARK CA
95682-7212
US

IV. Provider business mailing address

4120 CAMERON PARK DR SUITE 301
CAMERON PARK CA
95682-7212
US

V. Phone/Fax

Practice location:
  • Phone: 530-676-4555
  • Fax: 530-676-4555
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 5769
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT 6551
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN E. ROE
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 530-676-4555