Healthcare Provider Details

I. General information

NPI: 1487838843
Provider Name (Legal Business Name): RODERICK D. PENALOSA M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 INTERNATIONAL BLVD
OAKLAND CA
94606-2235
US

IV. Provider business mailing address

255 INTERNATIONAL BLVD.
OAKLAND CA
94606
US

V. Phone/Fax

Practice location:
  • Phone: 510-835-2777
  • Fax: 510-835-0164
Mailing address:
  • Phone: 510-835-2777
  • Fax: 510-835-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: