Healthcare Provider Details

I. General information

NPI: 1467692855
Provider Name (Legal Business Name): REBECA FISKE BAILEY PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 SYLVIA DR
GLEN ELLEN CA
95442-9308
US

IV. Provider business mailing address

178 SYLVIA DR
GLEN ELLEN CA
95442-9308
US

V. Phone/Fax

Practice location:
  • Phone: 707-939-0654
  • Fax: 707-996-9318
Mailing address:
  • Phone: 707-939-0654
  • Fax: 707-996-9318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY18732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: