Healthcare Provider Details

I. General information

NPI: 1245203538
Provider Name (Legal Business Name): LINDA R PARK MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PADRE PKWY STE 100
ROHNERT PARK CA
94928-2114
US

IV. Provider business mailing address

1265 CAMINO CORONADO
ROHNERT PARK CA
94928
US

V. Phone/Fax

Practice location:
  • Phone: 707-795-1599
  • Fax: 707-792-1600
Mailing address:
  • Phone: 707-795-1590
  • Fax: 707-792-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS2594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: