MEDICARE: AMY JAQUES GALUSHA 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	39482	CA

General Provider Information

NPI Number	:	1770879801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY JAQUES GALUSHA MFT

Provider Business Mailing Address
First Line	:	1500 PETALUMA BLVD S
Second Line	:	SUITE A
City	:	PETALUMA
State	:	CA
Zip	:	94952-5545
Country	:	US
Telephone Number	:	415-686-0000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 PETALUMA BLVD S
Second Line	:	SUITE A
City	:	PETALUMA
State	:	CA
Zip	:	94952-5545
Country	:	US
Telephone Number	:	415-686-0000
Fax Number	:

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

Provider Enumeration Date	:	06/27/2011
Last Update Date	:	06/27/2011

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