Healthcare Provider Details

I. General information

NPI: 1023944980
Provider Name (Legal Business Name): BURNSIDE THERAPY SOLUTIONS, MARRIAGE AND FAMILY THERAPY, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4865 OLD REDWOOD HWY
SANTA ROSA CA
95403-1415
US

IV. Provider business mailing address

1123 S CLOVERDALE BLVD STE E
CLOVERDALE CA
95425-4403
US

V. Phone/Fax

Practice location:
  • Phone: 707-494-6093
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: JAIME BURNSIDE
Title or Position: OWNER
Credential:
Phone: 707-494-6093