Provider Demographics
NPI:1932313400
Name:GREATER SANTA ROSA COUNCIL ON ALCOHOLISM
Entity type:Organization
Organization Name:GREATER SANTA ROSA COUNCIL ON ALCOHOLISM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-803-4955
Mailing Address - Street 1:1047 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2561
Mailing Address - Country:US
Mailing Address - Phone:575-472-5383
Mailing Address - Fax:
Practice Address - Street 1:1047 LAKE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2561
Practice Address - Country:US
Practice Address - Phone:575-472-5383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
NMLISW1041C0700X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000A3588Medicaid
NMNM000217OtherVALUE OPTIONS