Healthcare Provider Details

I. General information

NPI: 1255725313
Provider Name (Legal Business Name): LOMI PSYCHOTHERAPY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 B ST
SANTA ROSA CA
95401-5211
US

IV. Provider business mailing address

534 B ST
SANTA ROSA CA
95401-5211
US

V. Phone/Fax

Practice location:
  • Phone: 707-579-0465
  • Fax:
Mailing address:
  • Phone: 707-579-0465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberIMF64321
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberIMF6431
License Number StateCA

VIII. Authorized Official

Name: THOMAS POPE
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 707-579-0465