Healthcare Provider Details

I. General information

NPI: 1548274426
Provider Name (Legal Business Name): VERN LLOYD DWELLY MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 KIPLING DR
CARMICHAEL CA
95608-6067
US

IV. Provider business mailing address

4921 KIPLING DR
CARMICHAEL CA
95608-6067
US

V. Phone/Fax

Practice location:
  • Phone: 916-480-9807
  • Fax:
Mailing address:
  • Phone: 916-480-9807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC15239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: