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General NPI Number Information
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NPI Number | 1427362680
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Entity Type | Organization
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Legal Business Name | SONOMA MEMORY CENTER COMPREHENSIVE PSYCHOLOGY SERVICES PROFESSIONAL CO
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Dates
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Enumeration Date | 07/29/2010
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Last Update Date | 03/16/2011
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Provider Practice Location Address
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Address Line | 1111 SONOMA AVE STE 322
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City | SANTA ROSA
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State | CA
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Zip | 95405-4819
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Country | US
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Telephone | 707-546-3300
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Fax | 415-457-3819
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Provider Business Mailing Address
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Address Line | 1111 SONOMA AVE STE 322
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City | SANTA ROSA
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State | CA
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Zip | 95405-4819
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Country | US
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Telephone | 707-546-3300
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Fax | 415-457-3819
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDGAR O ANGELONE
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Credential | PHD
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Telephone | 707-546-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PSY13957
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License Number State | CA
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