Healthcare Provider Details

I. General information

NPI: 1962652883
Provider Name (Legal Business Name): ELLEN O'TOOLE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2008
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 FARMERS LN STE C
SANTA ROSA CA
95405-6712
US

IV. Provider business mailing address

1221 FARMERS LN STE C
SANTA ROSA CA
95405-6712
US

V. Phone/Fax

Practice location:
  • Phone: 707-829-5057
  • Fax:
Mailing address:
  • Phone: 707-829-5057
  • Fax: 707-829-5084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number22201
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number22201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: