Provider Demographics
NPI:1629196290
Name:REDWOOD PSYCHOLOGY CENTER, INC
Entity Type:Organization
Organization Name:REDWOOD PSYCHOLOGY CENTER, INC
Other - Org Name:RUSSIAN RIVER COUNSELORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:707-865-1200
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:MONTE RIO
Mailing Address - State:CA
Mailing Address - Zip Code:95462
Mailing Address - Country:US
Mailing Address - Phone:707-865-1200
Mailing Address - Fax:
Practice Address - Street 1:19375 HWY. 116
Practice Address - Street 2:
Practice Address - City:MONTE RIO
Practice Address - State:CA
Practice Address - Zip Code:95462
Practice Address - Country:US
Practice Address - Phone:707-865-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000330103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00PL39700Medicare PIN