Healthcare Provider Details

I. General information

NPI: 1679308134
Provider Name (Legal Business Name): SARA EMMANUEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 NORDYKE AVE
SANTA ROSA CA
95403-3122
US

IV. Provider business mailing address

2349 NORDYKE AVE
SANTA ROSA CA
95403-3122
US

V. Phone/Fax

Practice location:
  • Phone: 707-845-2248
  • Fax:
Mailing address:
  • Phone: 707-845-2248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5651
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: