=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285457150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAKER ALAN WILSON AMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2024
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16360 ROSCOE BLVD FL 2
-----------------------------------------------------
City | VAN NUYS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91406-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-207-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 312
-----------------------------------------------------
City | VERDUGO CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91046-0312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-207-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | AMFT147918
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------