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General NPI Number Information
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NPI Number | 1841605961
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Entity Type | Organization
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Legal Business Name | WILLIAM J. FORMAKER, MFT
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Dates
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Enumeration Date | 06/26/2014
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Last Update Date | 06/26/2014
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Provider Practice Location Address
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Address Line | 606 BEAVER ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-4228
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Country | US
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Telephone | 707-544-5717
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Fax | 707-887-8288
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Provider Business Mailing Address
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Address Line | 606 BEAVER ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-4228
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Country | US
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Telephone | 707-544-5717
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Fax | 707-887-8288
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Authorized Official
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Title or Position | OWNER
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Name | MR. WILLIAM J FORMAKER
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Credential | MFT
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Telephone | 707-544-5717
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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 | MFT29030
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License Number State | CA
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