Healthcare Provider Details

I. General information

NPI: 1396134615
Provider Name (Legal Business Name): THE CENTER FOR BODY ORIENTED PSYCHOTHERAPY & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 FOURTH STREET
SANTA ROSA CA
95404
US

IV. Provider business mailing address

1626 FOURTH STREET
SANTA ROSA CA
95404
US

V. Phone/Fax

Practice location:
  • Phone: 707-595-5637
  • Fax: 707-595-5637
Mailing address:
  • Phone: 707-595-5637
  • Fax: 707-595-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD A. SELCKE
Title or Position: FOUNDER, CLINICAL DIRECTOR
Credential: M.F.T.
Phone: 707-595-5637