=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629100276
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS W ROLLY LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 07/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 S WEED BLVD
-----------------------------------------------------
City | WEED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-859-3664
-----------------------------------------------------
Fax | 559-228-1106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 116
-----------------------------------------------------
City | WEED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-859-3664
-----------------------------------------------------
Fax | 559-228-1106
-----------------------------------------------------
=====================================================
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 | LMFT36040
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 36040
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------