Provider Demographics
NPI:1982485413
Name:PERFORMANCE PSYCHOLOGY CENTER
Entity Type:Organization
Organization Name:PERFORMANCE PSYCHOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-583-9663
Mailing Address - Street 1:2455 BENNETT VALLEY RD STE B208
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2455 BENNETT VALLEY RD STE B208
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5667
Practice Address - Country:US
Practice Address - Phone:707-583-9663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty