Provider Demographics
NPI:1962160655
Name:GNOODLE
Entity type:Organization
Organization Name:GNOODLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:775-354-9706
Mailing Address - Street 1:422 LARKFIELD CTR # 310
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1408
Mailing Address - Country:US
Mailing Address - Phone:775-354-9706
Mailing Address - Fax:
Practice Address - Street 1:5460 SKYLANE BLVD STE C
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1793
Practice Address - Country:US
Practice Address - Phone:775-354-9706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty