MEDICARE: BECKY LYNN COUNTER MFT INTERN

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 39699	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IMF39699	OTHER	CA	BBSE INTERN

General Provider Information

NPI Number	:	1578586012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BECKY LYNN COUNTER MFT INTERN

Provider Business Mailing Address
First Line	:	PO BOX 931
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95611-0931
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 ALBATROSS WAY STE 101
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95815-2878
Country	:	US
Telephone Number	:	916-631-0771
Fax Number	:

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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