Provider Demographics
NPI:1598805517
Name:BAILLERGEON, ROXANN J (MFT)
Entity Type:Individual
Prefix:MS
First Name:ROXANN
Middle Name:J
Last Name:BAILLERGEON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:ROXANN
Other - Middle Name:J
Other - Last Name:MOEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:242 N VILLA AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2641
Mailing Address - Country:US
Mailing Address - Phone:530-934-6582
Mailing Address - Fax:
Practice Address - Street 1:242 N VILLA AVE
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-2641
Practice Address - Country:US
Practice Address - Phone:530-934-6582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42843106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist