Healthcare Provider Details

I. General information

NPI: 1861915498
Provider Name (Legal Business Name): STEPHEN WILSEY LEUPOLD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
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: 707-565-4970
  • Fax:
Mailing address:
  • Phone: 707-565-4970
  • Fax: 707-565-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number40562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: