MEDICARE: THE CENTER FOR BODY ORIENTED PSYCHOTHERAPY & WELLNESS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist
2	103TC1900X	Counseling Psychologist
3	106H00000X	Marriage & Family Therapist
4	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1396134615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CENTER FOR BODY ORIENTED PSYCHOTHERAPY & WELLNESS

Provider Business Mailing Address
First Line	:	1626 FOURTH STREET
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404
Country	:	US
Telephone Number	:	707-595-5637
Fax Number	:	707-595-5637

Provider Business Practice Location Address
First Line	:	1626 FOURTH STREET
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404
Country	:	US
Telephone Number	:	707-595-5637
Fax Number	:	707-595-5637

Authorized Official
Title or Position	:	FOUNDER, CLINICAL DIRECTOR
Name	:	MR. RICHARD A. SELCKE
Credential	:	M.F.T.
Telephone Number	:	707-595-5637

Provider Enumeration Date	:	01/12/2015
Last Update Date	:	01/12/2015

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Directions to “THE CENTER FOR BODY ORIENTED PSYCHOTHERAPY & WELLNESS ” Practice Location

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