Provider Demographics
NPI:1700420650
Name:VILLAGOMEZ, CHARIS MANDUJANO
Entity Type:Individual
Prefix:
First Name:CHARIS
Middle Name:MANDUJANO
Last Name:VILLAGOMEZ
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 1:2403 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3007
Mailing Address - Country:US
Mailing Address - Phone:707-544-3295
Mailing Address - Fax:
Practice Address - Street 1:2403 PROFESSIONAL DR STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3007
Practice Address - Country:US
Practice Address - Phone:707-544-3295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)