Provider Demographics
NPI:1790325694
Name:PACIFIC FORENSIC PSYCHOLOGY ASSOCIATES, INC
Entity Type:Organization
Organization Name:PACIFIC FORENSIC PSYCHOLOGY ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / PRINCIPLE
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-395-4500
Mailing Address - Street 1:19230 SONOMA HIGHWAY
Mailing Address - Street 2:BUILDING 200
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476
Mailing Address - Country:US
Mailing Address - Phone:916-224-0212
Mailing Address - Fax:
Practice Address - Street 1:19230 SONOMA HIGHWAY
Practice Address - Street 2:BUILDING 200
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476
Practice Address - Country:US
Practice Address - Phone:916-224-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder