Healthcare Provider Details

I. General information

NPI: 1063557171
Provider Name (Legal Business Name): LIFEWORKS OF SONOMA COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date: 05/28/2015
Reactivation Date: 07/30/2015

III. Provider practice location address

1260 N DUTTON AVE STE 220
SANTA ROSA CA
95401-4686
US

IV. Provider business mailing address

1260 N DUTTON AVE STE 220
SANTA ROSA CA
95401-4686
US

V. Phone/Fax

Practice location:
  • Phone: 707-568-2300
  • Fax: 707-568-2304
Mailing address:
  • Phone: 707-568-2300
  • Fax: 707-568-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE FOUNTAIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 707-568-2300