MEDICARE: MY NICHE FAMILY THERAPY PROFESSIONAL CORPORATION

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

General Provider Information

NPI Number	:	1801755269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY NICHE FAMILY THERAPY PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	346 ROCKHURST CT
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-1241
Country	:	US
Telephone Number	:	707-475-3203
Fax Number	:	707-439-3037

Provider Business Practice Location Address
First Line	:	825 WEBSTER ST STE B
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5522
Country	:	US
Telephone Number	:	707-475-3203
Fax Number	:	707-439-3037

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES THOMAS ANDERSON
Credential	:	LMFT
Telephone Number	:	707-386-8066

Provider Enumeration Date	:	01/20/2026
Last Update Date	:	01/20/2026

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Directions to “MY NICHE FAMILY THERAPY PROFESSIONAL CORPORATION ” Practice Location

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