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General NPI Number Information
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NPI Number | 1487908620
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Entity Type | Organization
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Legal Business Name | MISSING ELEMENTS
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Dates
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Enumeration Date | 11/08/2012
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Last Update Date | 04/01/2024
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Provider Practice Location Address
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Address Line | 1717 YULUPA AVE STE 5
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City | SANTA ROSA
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State | CA
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Zip | 95405-6201
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Country | US
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Telephone | 707-560-1051
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Fax | 866-803-4979
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Provider Business Mailing Address
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Address Line | PO BOX 882
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City | SANTA ROSA
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State | CA
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Zip | 95402-0882
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Country | US
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Telephone | 707-560-1051
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Fax | 866-803-4979
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | SUZE CRIBBS
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Credential | LMFT
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Telephone | 707-560-1051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | IMF55305
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License Number State | CA
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