MEDICARE: VETERANS ADMINISTRATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	C19197	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C19197	OTHER	CA	MEDICAL BOARD NUMBER

General Provider Information

NPI Number	:	1235230848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VETERANS ADMINISTRATION

Provider Business Mailing Address
First Line	:	3315 CHANATE RD STE 1B
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-1740
Country	:	US
Telephone Number	:	707-570-3800
Fax Number	:	707-570-3860

Provider Business Practice Location Address
First Line	:	3315 CHANATE RD STE 1B
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-1740
Country	:	US
Telephone Number	:	707-570-3800
Fax Number	:	707-570-3860

Authorized Official
Title or Position	:	STAFF PSYCHIATRIST
Name	:	DR. DONALD BLAIR DEAN
Credential	:	MD
Telephone Number	:	707-570-3800

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	03/07/2023

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Directions to “VETERANS ADMINISTRATION ” Practice Location

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