Healthcare Provider Details

I. General information

NPI: 1982334710
Provider Name (Legal Business Name): MARIA DE JESUS DALIA VILLAGOMEZ PULIDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

IV. Provider business mailing address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-8181
  • Fax: 707-565-5183
Mailing address:
  • Phone: 707-576-8181
  • Fax: 707-565-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number142146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: