MEDICARE: MRS. GENOLA I SPOONHOUR LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LMFT16646	CA

General Provider Information

NPI Number	:	1063584662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GENOLA I SPOONHOUR LMFT

Provider Business Mailing Address
First Line	:	2155 WEST MARCH LANE
Second Line	:	2B
City	:	STOCKTON
State	:	CA
Zip	:	95207
Country	:	US
Telephone Number	:	209-473-4211
Fax Number	:	209-473-0610

Provider Business Practice Location Address
First Line	:	2155 WEST MARCH LANE
Second Line	:	2B
City	:	STOCKTON
State	:	CA
Zip	:	95207
Country	:	US
Telephone Number	:	209-473-4211
Fax Number	:	209-473-0610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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