Healthcare Provider Details

I. General information

NPI: 1053522508
Provider Name (Legal Business Name): LIFEWORKS OF SONOMA COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5154 SNYDER LANE
ROHNERT PARK CA
94928-2943
US

IV. Provider business mailing address

1200 COLLEGE AVENUE
SANTA ROSA CA
95404-3908
US

V. Phone/Fax

Practice location:
  • Phone: 707-585-6283
  • Fax: 707-588-5607
Mailing address:
  • Phone: 707-568-2300
  • Fax: 707-568-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPSY 13055
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. JILL W. ROYCE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 707-568-2300