Provider Demographics
NPI:1619414653
Name:BAY AREA MUSIC THERAPY LLC
Entity Type:Organization
Organization Name:BAY AREA MUSIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MUSIC THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MT-BC
Authorized Official - Phone:707-595-0995
Mailing Address - Street 1:1007 W COLLEGE AVE # 176
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5046
Mailing Address - Country:US
Mailing Address - Phone:707-595-0995
Mailing Address - Fax:
Practice Address - Street 1:1924 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2647
Practice Address - Country:US
Practice Address - Phone:707-595-0995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Multi-Specialty