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NPI Code Detail

MEDICARE: MISS TRACIE ANN WISHART MFT

MEDICARE: MISS TRACIE ANN WISHART MFT
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
1106H00000XMarriage & Family TherapistMFC 39429CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MFC 39429OTHERCAMARRIAGE FAMILY THERAPIST

General Provider Information

NPI Number : 1316058407
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS TRACIE ANN WISHART MFT
Provider Business Mailing Address
First Line : 341 IRWIN LN
Second Line :
City : SANTA ROSA
State : CA
Zip : 95401-5603
Country : US
Telephone Number : 707-360-1904
Fax Number :
Provider Business Practice Location Address
First Line : 341 IRWIN LN
Second Line :
City : SANTA ROSA
State : CA
Zip : 95401-5603
Country : US
Telephone Number : 707-360-1904
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2006
Last Update Date : 07/08/2007

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Directions to “ MISS TRACIE ANN WISHART MFT” Practice Location

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