Provider Demographics
NPI:1336686369
Name:BRIDGES TO SELF EMPOWERMENT A MARRIAGE AND FAMILY THERAPIST CORPORATIO
Entity Type:Organization
Organization Name:BRIDGES TO SELF EMPOWERMENT A MARRIAGE AND FAMILY THERAPIST CORPORATIO
Other - Org Name:ALICE PETTY-HANNUM MFT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATION OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:PETTY-HANNUM
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:707-495-5350
Mailing Address - Street 1:406 CHINN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4339
Mailing Address - Country:US
Mailing Address - Phone:707-495-5350
Mailing Address - Fax:707-570-2680
Practice Address - Street 1:406 CHINN ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4339
Practice Address - Country:US
Practice Address - Phone:707-495-5350
Practice Address - Fax:707-570-2680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIDGES TO SELF EMPOWERMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43967251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health