Provider Demographics
NPI:1194582353
Name:DARDIS, BRIANNA
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:DARDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 BERRYDALE DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-4359
Mailing Address - Country:US
Mailing Address - Phone:707-338-5435
Mailing Address - Fax:
Practice Address - Street 1:819 3RD ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4545
Practice Address - Country:US
Practice Address - Phone:707-303-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119619104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker