=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639941065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARA FLOR-VERA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2023
-----------------------------------------------------
Last Update Date | 11/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1349 MANHATTAN WAY
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-569-4823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1349 MANHATTAN WAY
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-569-4823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 75656
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------