Provider Demographics
NPI: | 1033127972 |
---|---|
Name: | BOAZ, PAMELA A (PHD MFT) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | PAMELA |
Middle Name: | A |
Last Name: | BOAZ |
Suffix: | |
Gender: | F |
Credentials: | PHD MFT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 659 CHERRY ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SANTA ROSA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95404-4202 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 707-526-8300 |
Mailing Address - Fax: | 707-526-8310 |
Practice Address - Street 1: | 659 CHERRY ST |
Practice Address - Street 2: | |
Practice Address - City: | SANTA ROSA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95404-4202 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-526-8300 |
Practice Address - Fax: | 707-526-8310 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-04 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | PSY16196 | 103TC0700X |
CA | MFT19314 | 106H00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Not Answered | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | BHZZZ702682 | Medicare ID - Type Unspecified |