Healthcare Provider Details

I. General information

NPI: 1063974210
Provider Name (Legal Business Name): IVONNE RUBIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 BRITTAIN LN
SANTA ROSA CA
95401-5810
US

IV. Provider business mailing address

1465 BEACHWOOD DR APT B
SANTA ROSA CA
95407-7063
US

V. Phone/Fax

Practice location:
  • Phone: 707-525-8350
  • Fax:
Mailing address:
  • Phone: 760-620-1554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: