MEDICARE: MARY VERONICA MCCAMMON 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	101YM0800X	Mental Health Counselor	124805	CA

General Provider Information

NPI Number	:	1871160374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY VERONICA MCCAMMON LMFT

Provider Business Mailing Address
First Line	:	2777 YULUPA AVE # 156
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-8584
Country	:	US
Telephone Number	:	707-481-4778
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 CREEKSIDE RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-8404
Country	:	US
Telephone Number	:	707-545-8264
Fax Number	:

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

Provider Enumeration Date	:	06/04/2021
Last Update Date	:	06/04/2021

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