Healthcare Provider Details

I. General information

NPI: 1619295839
Provider Name (Legal Business Name): LIFEWORKS OF SONOMA COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 N DUTTON AVE STE 105 & STE 244
SANTA ROSA CA
95401
US

IV. Provider business mailing address

1260 N DUTTON AVE STE 105 & STE 244
SANTA ROSA CA
95401-7121
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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

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