=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871582965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN PRATT BINGHAM M.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9851 HORN RD SUITE 180
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95827-1993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-366-0164
-----------------------------------------------------
Fax | 916-366-0149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4940 ARTESIA RD
-----------------------------------------------------
City | SHINGLE SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95682-9515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-676-9050
-----------------------------------------------------
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 | MFT 14489
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------