MEDICARE: COUNSELING CENTER OF MARRIAGE AND FAMILY THERAPY CORP

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	101YP2500X	Professional Counselor	53299	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	474351682	OTHER	CA	TAX ID

General Provider Information

NPI Number	:	1205339215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING CENTER OF MARRIAGE AND FAMILY THERAPY CORP

Provider Business Mailing Address
First Line	:	401B VERNON STREET
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95678
Country	:	US
Telephone Number	:	916-581-0054
Fax Number	:

Provider Business Practice Location Address
First Line	:	3330 CAMERON PARK DR STE 400
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-7652
Country	:	US
Telephone Number	:	916-581-0054
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY SALMON
Credential	:	LMFT
Telephone Number	:	916-581-0054

Provider Enumeration Date	:	03/15/2018
Last Update Date	:	02/26/2020

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