Provider Demographics
NPI:1104131234
Name:SANTA ROSA ADULT & CHILD CENTER FOR COGNITIVE BEHAVIORAL THERAPY
Entity type:Organization
Organization Name:SANTA ROSA ADULT & CHILD CENTER FOR COGNITIVE BEHAVIORAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LITSA
Authorized Official - Middle Name:R
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:707-545-4600
Mailing Address - Street 1:319 S E ST STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5132
Mailing Address - Country:US
Mailing Address - Phone:707-054-5460
Mailing Address - Fax:
Practice Address - Street 1:319 S E ST STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5132
Practice Address - Country:US
Practice Address - Phone:707-054-5460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty