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General NPI Number Information
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NPI Number | 1124957030
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Entity Type | Organization
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Legal Business Name | MYCELIUM FAMILY THERAPY, PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 05/16/2026
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Last Update Date | 05/16/2026
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Provider Practice Location Address
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Address Line | 7 PAGE ST STE B
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City | COTATI
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State | CA
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Zip | 94931-4532
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Country | US
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Telephone | 707-782-2419
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Fax |
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Provider Business Mailing Address
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Address Line | 7 PAGE ST STE B
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City | COTATI
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State | CA
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Zip | 94931-4532
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Country | US
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Telephone | 707-782-2419
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, CEO
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Name | LACEY LYNN PALMER
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Credential | PHD, LMFT
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Telephone | 707-782-2419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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