Provider Demographics
NPI:1568911964
Name:PETALUMA FAMILY THERAPY
Entity Type:Organization
Organization Name:PETALUMA FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:707-772-5085
Mailing Address - Street 1:405 E D ST STE 105
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3173
Mailing Address - Country:US
Mailing Address - Phone:707-772-5085
Mailing Address - Fax:
Practice Address - Street 1:405 E D ST STE 105
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3173
Practice Address - Country:US
Practice Address - Phone:707-772-5085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50183106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty