Provider Demographics
NPI:1609075654
Name:POPPLEWELL, MICHAEL DOUGLAS (MFTI #78455)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:POPPLEWELL
Suffix:
Gender:M
Credentials:MFTI #78455
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2519
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94927-2519
Mailing Address - Country:US
Mailing Address - Phone:415-729-4180
Mailing Address - Fax:415-480-2880
Practice Address - Street 1:755 BAYWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5508
Practice Address - Country:US
Practice Address - Phone:415-729-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
CA78455106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health