Provider Demographics
NPI:1679624142
Name:NORVILLE, ROXANA LEIGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROXANA
Middle Name:LEIGH
Last Name:NORVILLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 2ND ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-3695
Mailing Address - Country:US
Mailing Address - Phone:650-948-4864
Mailing Address - Fax:650-948-4436
Practice Address - Street 1:350 2ND ST
Practice Address - Street 2:SUITE 4
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-3695
Practice Address - Country:US
Practice Address - Phone:650-948-4864
Practice Address - Fax:650-948-4436
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12118103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY121180Medicaid
CAPSY12118OtherLICENSED PSYCHOLOGIST
CA0PL121180Medicare ID - Type UnspecifiedLICENSED PSYCHOLOGIST
CAPSY121180Medicaid