Provider Demographics
NPI:1144393638
Name:FOOTE, IVAN WILLIAM (LMFT)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:WILLIAM
Last Name:FOOTE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7814
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95061-7814
Mailing Address - Country:US
Mailing Address - Phone:831-475-5826
Mailing Address - Fax:
Practice Address - Street 1:232 E GISH RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4706
Practice Address - Country:US
Practice Address - Phone:408-876-4104
Practice Address - Fax:408-876-4230
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT36805106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist