Provider Demographics
NPI:1487846069
Name:SONOMA MEMORY CLINIC
Entity Type:Organization
Organization Name:SONOMA MEMORY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-544-4441
Mailing Address - Street 1:401 S A ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-8518
Mailing Address - Country:US
Mailing Address - Phone:707-544-4441
Mailing Address - Fax:
Practice Address - Street 1:401 S A ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-8518
Practice Address - Country:US
Practice Address - Phone:707-544-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty