MEDICARE: RUTH MARYA FANKUSHEN 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	IMF 74268	CA
2	106H00000X	Marriage & Family Therapist	94555	CA

General Provider Information

NPI Number	:	1386055341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUTH MARYA FANKUSHEN LMFT

Provider Business Mailing Address
First Line	:	2655 PORTAGE BAY E STE 4
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95616-3073
Country	:	US
Telephone Number	:	530-507-8647
Fax Number	:	530-302-3388

Provider Business Practice Location Address
First Line	:	2655 PORTAGE BAY E STE 4
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95616-3073
Country	:	US
Telephone Number	:	530-507-8647
Fax Number	:	530-302-3388

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

Provider Enumeration Date	:	05/13/2014
Last Update Date	:	09/19/2018

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