Healthcare Provider Details

I. General information

NPI: 1790186534
Provider Name (Legal Business Name): MARISELA SEDANO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 CAPRICORN WAY, SUITE 207
SANTA ROSA CA
95407
US

IV. Provider business mailing address

12 RAMBLE CREEK DR
COTATI CA
94931-4321
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4990
  • Fax:
Mailing address:
  • Phone: 707-971-9834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number81676
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number104470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: