Healthcare Provider Details

I. General information

NPI: 1952906299
Provider Name (Legal Business Name): LAUREN ELIZABETH AXBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S E ST
SANTA ROSA CA
95404-4709
US

IV. Provider business mailing address

8025 BEVERLY DR APT 105
ROHNERT PARK CA
94928-4003
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-6960
  • Fax: 707-573-6961
Mailing address:
  • Phone: 310-697-6621
  • Fax:

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:
Title or Position:
Credential:
Phone: