Healthcare Provider Details

I. General information

NPI: 1851644371
Provider Name (Legal Business Name): MS. AMANDA JOHANNA MENARY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. AMANDA JOHANNA AARON

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 CLEVELAND AVE
SANTA ROSA CA
95401-4282
US

IV. Provider business mailing address

612 PALOMINO DR
SANTA ROSA CA
95401-5409
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-0818
  • Fax: 707-576-7845
Mailing address:
  • Phone: 707-484-3411
  • Fax: 707-576-7845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT36689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: