Healthcare Provider Details

I. General information

NPI: 1366114464
Provider Name (Legal Business Name): RADIANT BEGINNINGS MARRIAGE CHILD & FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 VICKSBURG DR
FAIRFIELD CA
94533-5166
US

IV. Provider business mailing address

1651 VICKSBURG DR
FAIRFIELD CA
94533-5166
US

V. Phone/Fax

Practice location:
  • Phone: 707-654-4659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MALLORY WALTERS
Title or Position: OWNER/PROVIDER
Credential: LMFT
Phone: 707-654-4659