MEDICARE: MR. GARY L MOLINE 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
1	106H00000X	Marriage & Family Therapist	MFC 015483	CA

General Provider Information

NPI Number	:	1518176643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY L MOLINE MFT

Provider Business Mailing Address
First Line	:	73 SAINT JAMES DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1419
Country	:	US
Telephone Number	:	707-571-1714
Fax Number	:

Provider Business Practice Location Address
First Line	:	73 SAINT JAMES DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1419
Country	:	US
Telephone Number	:	707-571-1714
Fax Number	:

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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