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General NPI Number Information
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NPI Number | 1982485413
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Entity Type | Organization
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Legal Business Name | PERFORMANCE PSYCHOLOGY CENTER
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Dates
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Enumeration Date | 10/10/2023
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | 2455 BENNETT VALLEY RD STE B208
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City | SANTA ROSA
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State | CA
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Zip | 95404-5667
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Country | US
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Telephone | 707-583-9663
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Fax |
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Provider Business Mailing Address
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Address Line | 2455 BENNETT VALLEY RD STE B208
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City | SANTA ROSA
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State | CA
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Zip | 95404-5667
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST, OWNER
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Name | JOSEPH PUENTES
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Credential | PSY.D.
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Telephone | 707-583-9663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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