Provider Demographics
NPI:1619639903
Name:MAIKE, JOHN EDWARD (LMFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:MAIKE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 EDMONDALE CT
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9232
Mailing Address - Country:US
Mailing Address - Phone:707-301-1036
Mailing Address - Fax:
Practice Address - Street 1:137 EDMONDALE CT
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9232
Practice Address - Country:US
Practice Address - Phone:707-301-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT50284106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist