Healthcare Provider Details

I. General information

NPI: 1487908620
Provider Name (Legal Business Name): MISSING ELEMENTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 YULUPA AVE STE 5
SANTA ROSA CA
95405-6201
US

IV. Provider business mailing address

PO BOX 882
SANTA ROSA CA
95402-0882
US

V. Phone/Fax

Practice location:
  • Phone: 707-560-1051
  • Fax: 866-803-4979
Mailing address:
  • Phone: 707-560-1051
  • Fax: 866-803-4979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberIMF55305
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SUZE CRIBBS
Title or Position: CLINICAL DIRECTOR
Credential: LMFT
Phone: 707-560-1051