Provider Demographics
NPI:1598053928
Name:BROMLEY, GEORGE WILLIAM JR (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:WILLIAM
Last Name:BROMLEY
Suffix:JR
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 AIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2065
Mailing Address - Country:US
Mailing Address - Phone:707-800-3954
Mailing Address - Fax:
Practice Address - Street 1:3440 AIRWAY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2065
Practice Address - Country:US
Practice Address - Phone:707-800-3954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF69971106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist