Provider Demographics
NPI:1366940504
Name:NEW LEAF COUNSELING AND PSYCHOTHERAPY
Entity type:Organization
Organization Name:NEW LEAF COUNSELING AND PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:JANET
Authorized Official - Last Name:WHITLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:707-387-8414
Mailing Address - Street 1:1030 2N STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404
Mailing Address - Country:US
Mailing Address - Phone:707-387-4146
Mailing Address - Fax:707-843-5608
Practice Address - Street 1:1030 2N STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-387-4146
Practice Address - Fax:707-843-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84009106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========7Medicaid