Individual provider Active NPI

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  • Clinical Psychologist
  • Rohnert Park, CA
National Provider Identifier
1760850770
Registry record updated Apr 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
PSB94021384 Issued in CA
Practice address
5789 State Farm Dr Ste 195
Rohnert Park, CA 94928-6310
Phone
(510) 647-5101
NPI assigned
Sep 8, 2015
Last updated
Apr 11, 2025By the provider in NPPES
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Apr 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X PSB94021384 CA Primary

Addresses

Primary practice location

5789 State Farm Dr Ste 195
Rohnert Park, CA 94928-6310

Mailing address

1335 Stanford Ave
Emeryville, CA 94608-2536
Phone (510) 647-5101

Other practice location 1

155 E 54th St
San Bernardino, CA 92404-1116
Phone (909) 553-1386

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA
Eligible to order & refer
  • Part B services: No
  • Medical equipment: Yes
  • Home health: No
  • Power mobility devices: No
  • Hospice: No
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250403002704 CA Practitioner - Clinical Psychologist 2163946807 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
PSB94021384CAMDClinical Psychologist

Practice roles

OrganizationSpecialtyStatusNew patients
Valley Surgery Center CurrentSince Apr 13, 2025 Accepting new patients
Pain and Rehabilitative Consultants Medical Group CurrentSince Feb 21, 2025 Accepting new patients
Teodoro P. Nissen M.D., Inc PastSince Feb 21, 2025 Accepting new patients

Locations

1335 Stanford Ave
Emeryville, CA 94608
Phone (510) 649-7000

5789 State Farm Dr
Ste 195
Rohnert Park, CA 94928
Phone (707) 645-7210

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1441670400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1744329600000",
    "number": "1760850770",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1335 STANFORD AVE",
            "city": "EMERYVILLE",
            "state": "CA",
            "postal_code": "946082536",
            "telephone_number": "510-647-5101"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5789 STATE FARM DR STE 195",
            "city": "ROHNERT PARK",
            "state": "CA",
            "postal_code": "949286310",
            "telephone_number": "510-647-5101"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "155 E 54th St",
            "address_purpose": "LOCATION",
            "city": "San Bernardino",
            "state": "CA",
            "postal_code": "924041116",
            "country_code": "US",
            "telephone_number": "909-553-1386",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FOOTE",
        "first_name": "BARBARADEE",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2015-09-08",
        "last_updated": "2025-04-11",
        "certification_date": "2025-04-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSB94021384",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rohnert Park, CA

Sources for this page

Verify at the official NPI Registry.