Healthcare Provider Details

I. General information

NPI: 1215147244
Provider Name (Legal Business Name): CAROLYN LOUISE WEATHERUP LICENSED MARRIAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 6TH STREET
MARYSVILLE CA
95901
US

IV. Provider business mailing address

209 6TH STREET
MARYSVILLE CA
95901
US

V. Phone/Fax

Practice location:
  • Phone: 530-741-6275
  • Fax: 530-749-7913
Mailing address:
  • Phone: 530-741-6275
  • Fax: 530-749-7913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC39648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: