1912040445 NPI number — MRS. AMY HERREMA CHEVROLET LCSW

Table of content: MRS. AMY HERREMA CHEVROLET LCSW (NPI 1912040445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912040445 NPI number — MRS. AMY HERREMA CHEVROLET LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEVROLET
Provider First Name:
AMY
Provider Middle Name:
HERREMA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912040445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10340 WOODSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORESTVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95436-9806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-308-9538
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
KEYSTONE THERAPY AND TRAINING SERVICES
Provider Second Line Business Practice Location Address:
4415 SONOMA HWY STE A
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95409-4165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-308-9538
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  20436 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCS20436 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)