=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255601043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERTA CARDWELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2012
-----------------------------------------------------
Last Update Date | 01/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3315 AIRWAY DR
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-523-2242
-----------------------------------------------------
Fax | 707-546-1937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 HORN AVE
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95407-8242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-623-3260
-----------------------------------------------------
Fax | 707-586-1802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------