Healthcare Provider Details

I. General information

NPI: 1861848178
Provider Name (Legal Business Name): CARRIE CANINE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 CALISTOGA RD # 623
SANTA ROSA CA
95409-3702
US

IV. Provider business mailing address

122 CALISTOGA RD # 623
SANTA ROSA CA
95409-3702
US

V. Phone/Fax

Practice location:
  • Phone: 510-517-6199
  • Fax:
Mailing address:
  • Phone: 510-517-6199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number114060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: