Provider Demographics
NPI:1154768307
Name:REDWOOD PSYCHOLOGY CENTER, INC.
Entity type:Organization
Organization Name:REDWOOD PSYCHOLOGY CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRID
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:707-865-1200
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:MONTE RIO
Mailing Address - State:CA
Mailing Address - Zip Code:95462-0519
Mailing Address - Country:US
Mailing Address - Phone:707-865-1200
Mailing Address - Fax:707-865-3151
Practice Address - Street 1:709 DAVIS ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4767
Practice Address - Country:US
Practice Address - Phone:707-525-9223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000330103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty