Provider Demographics
NPI:1013469048
Name:MINEO, ROBERTA LATEFA (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LATEFA
Last Name:MINEO
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:PO BOX 329
Mailing Address - Street 2:
Mailing Address - City:GRATON
Mailing Address - State:CA
Mailing Address - Zip Code:95444-0329
Mailing Address - Country:US
Mailing Address - Phone:707-953-1139
Mailing Address - Fax:
Practice Address - Street 1:3291 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-9388
Practice Address - Country:US
Practice Address - Phone:707-953-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32488103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty