Basic Information
| Provider Information | |||||||||
| NPI: | 1861845968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETCHEVERRY | ||||||||
| FirstName: | LAYNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949522620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072390384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2403 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075443295 | ||||||||
| FaxNumber: | 7075449011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2016 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.