Provider Demographics
NPI:1568695245
Name:DE LA O, RUDOLPHO EDUARDO (RAS)
Entity Type:Individual
Prefix:
First Name:RUDOLPHO
Middle Name:EDUARDO
Last Name:DE LA O
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 AIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2005
Mailing Address - Country:US
Mailing Address - Phone:707-523-2242
Mailing Address - Fax:707-526-3817
Practice Address - Street 1:3315 AIRWAY DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-523-2242
Practice Address - Fax:707-523-3817
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD0501021429101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)