Healthcare Provider Details

I. General information

NPI: 1871238311
Provider Name (Legal Business Name): ANN STRACK, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 WESTERN AVE
PETALUMA CA
94952-2919
US

IV. Provider business mailing address

318 WESTERN AVE
PETALUMA CA
94952-2919
US

V. Phone/Fax

Practice location:
  • Phone: 707-762-6216
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANNETTE STRACK
Title or Position: OWNER
Credential:
Phone: 707-762-6216