Basic Information
| Provider Information | |||||||||
| NPI: | 1366905051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 440 ARROWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954077503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072842950 | ||||||||
| FaxNumber: | 7072842955 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 ARROWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954077503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072842950 | ||||||||
| FaxNumber: | 7072842955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2019 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1339900319 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 101YA0400X | 05 | CA | MEDICAID |