Provider Demographics
NPI:1093851537
Name:VELIQUETTE, MAURICE WAYNE (MFT)
Entity Type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:WAYNE
Last Name:VELIQUETTE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:BUD
Other - Middle Name:
Other - Last Name:VELIQUETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:JENNER
Mailing Address - State:CA
Mailing Address - Zip Code:95450-0155
Mailing Address - Country:US
Mailing Address - Phone:707-865-1699
Mailing Address - Fax:
Practice Address - Street 1:534 B STREET
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:707-246-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37457106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist