Provider Demographics
NPI:1598187882
Name:BUCHANAN, MOLLIE
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PETALUMA BLVD S
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-5545
Mailing Address - Country:US
Mailing Address - Phone:707-765-8488
Mailing Address - Fax:707-765-8482
Practice Address - Street 1:1500 PETALUMA BLVD S
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5545
Practice Address - Country:US
Practice Address - Phone:707-765-8488
Practice Address - Fax:707-765-8482
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59614106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist