=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619084043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLOTTE ADAMS MFT INTERN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3307 BROADWAY STE 200
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95817-2821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-454-4242
-----------------------------------------------------
Fax | 916-454-2930
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2616 MARSH WREN WAY
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95757-8185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-685-3238
-----------------------------------------------------
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 | IMF47052
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------