Provider Demographics
NPI:1043953961
Name:FERDA, LYNNE
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:FERDA
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:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-0339
Mailing Address - Country:US
Mailing Address - Phone:707-640-0722
Mailing Address - Fax:707-640-1922
Practice Address - Street 1:450 S PORTER RD STE D
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-3358
Practice Address - Country:US
Practice Address - Phone:707-640-0722
Practice Address - Fax:707-640-1922
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness