Healthcare Provider Details

I. General information

NPI: 1740490176
Provider Name (Legal Business Name): CILPSI SPECIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 FULTON RD
SANTA ROSA CA
95403-1815
US

IV. Provider business mailing address

1200 COLLEGE AVE
SANTA ROSA CA
95404-3908
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 NumberPSY13055
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL K TONJUM
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 707-568-2300