Basic Information
| Provider Information | |||||||||
| NPI: | 1679025472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRESS FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HARSTAD HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 368 FELL ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941025144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158610828 | ||||||||
| FaxNumber: | 4158610257 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 GORDON LN | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954045636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072559028 | ||||||||
| FaxNumber: | 7072553715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2016 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NAVARRO-SIMEON | ||||||||
| AuthorizedOfficialFirstName: | BERNADETTE | ||||||||
| AuthorizedOfficialMiddleName: | SANTIAGO | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 4158610828 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROGRESS FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 496803654 | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 49GH5 | 05 | CA | MEDICAID |