Provider Demographics
NPI:1225309677
Name:BASHAW, MICHELLE ROSE (MFT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:BASHAW
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:ROSE
Other - Last Name:BASHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:PO BOX 1662
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95473-1662
Mailing Address - Country:US
Mailing Address - Phone:707-775-5909
Mailing Address - Fax:
Practice Address - Street 1:7385 HEALDSBURG AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3224
Practice Address - Country:US
Practice Address - Phone:707-775-5909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 41623106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist