Provider Demographics
NPI:1497390009
Name:PURUGGANAN, ALEXIS RENEE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:RENEE
Last Name:PURUGGANAN
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 1:2447 SUMMERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7815
Mailing Address - Country:US
Mailing Address - Phone:707-544-3299
Mailing Address - Fax:
Practice Address - Street 1:3419 VALLE VERDE DR
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2414
Practice Address - Country:US
Practice Address - Phone:707-299-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 390200000X
CA105757104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program