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General NPI Number Information
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NPI Number | 1386055341
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Entity Type | Individual
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Provider Name | RUTH MARYA FANKUSHEN LMFT
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Gender | Female
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 09/19/2018
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Provider Practice Location Address
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Address Line | 2655 PORTAGE BAY E STE 4
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City | DAVIS
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State | CA
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Zip | 95616-3073
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Country | US
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Telephone | 530-507-8647
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Fax | 530-302-3388
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Provider Business Mailing Address
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Address Line | 2655 PORTAGE BAY E STE 4
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City | DAVIS
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State | CA
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Zip | 95616-3073
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Country | US
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Telephone | 530-507-8647
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Fax | 530-302-3388
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | IMF 74268
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 94555
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License Number State | CA
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