MEDICARE: IMOGEN WORMWOOD

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	251300000X	Local Education Agency (LEA)		CA
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1669046389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMOGEN WORMWOOD

Provider Business Mailing Address
First Line	:	447 SEBASTOPOL AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-8502
Country	:	US
Telephone Number	:	707-766-4810
Fax Number	:

Provider Business Practice Location Address
First Line	:	4415 SONOMA HWY
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-7100
Country	:	US
Telephone Number	:	707-327-0909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2021
Last Update Date	:	09/04/2025

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Directions to “ IMOGEN WORMWOOD ” Practice Location

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