Healthcare Provider Details

I. General information

NPI: 1780048421
Provider Name (Legal Business Name): EASTER SEALS BAY AREA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 WIKIUP DRIVE, SUITE 102
SANTA ROSA CA
95403
US

IV. Provider business mailing address

2730 SHADELANDS DRIVE, BLDG. 10
WALNUT CREEK CA
94598
US

V. Phone/Fax

Practice location:
  • Phone: 707-843-3745
  • Fax:
Mailing address:
  • Phone: 925-266-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateCA

VIII. Authorized Official

Name: SUSAN ARMIGER
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 925-266-8400