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General NPI Number Information
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NPI Number | 1336686369
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Entity Type | Organization
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Legal Business Name | BRIDGES TO SELF EMPOWERMENT A MARRIAGE AND FAMILY THERAPIST CORPORATIO
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Dates
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Enumeration Date | 01/29/2017
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Last Update Date | 01/29/2017
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Provider Practice Location Address
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Address Line | 406 CHINN ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-4339
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Country | US
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Telephone | 707-495-5350
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Fax | 707-570-2680
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Provider Business Mailing Address
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Address Line | 406 CHINN ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-4339
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Country | US
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Telephone | 707-495-5350
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Fax | 707-570-2680
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Authorized Official
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Title or Position | CORPORATION OWNER
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Name | ALICE DEE PETTY-HANNUM
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Credential | MFT
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Telephone | 707-495-5350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | MFC43967
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License Number State | CA
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