Healthcare Provider Details

I. General information

NPI: 1790604726
Provider Name (Legal Business Name): LEAH SYRAH LAWRENCE AA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 B ST
SANTA ROSA CA
95401-5211
US

IV. Provider business mailing address

3533 THORN RD
SEBASTOPOL CA
95472-5345
US

V. Phone/Fax

Practice location:
  • Phone: 707-920-5434
  • Fax:
Mailing address:
  • Phone: 707-920-5434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberY8892987
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: