MEDICARE: CHARLES ANTHONY CRAIN LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	87978	CA

General Provider Information

NPI Number	:	1144774035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES ANTHONY CRAIN LMFT

Provider Business Mailing Address
First Line	:	PO BOX 2951
Second Line	:
City	:	ROHNERT PARK
State	:	CA
Zip	:	94927-2951
Country	:	US
Telephone Number	:	707-293-0010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1023 4TH ST
Second Line	:	SUITE F & G
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-4301
Country	:	US
Telephone Number	:	707-293-0010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2016
Last Update Date	:	02/11/2022

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