Provider Demographics
NPI:1649737016
Name:BROOKS MOTL, MARYJO (LMFT)
Entity Type:Individual
Prefix:
First Name:MARYJO
Middle Name:
Last Name:BROOKS MOTL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 STONE BLVD STE 175
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-4055
Mailing Address - Country:US
Mailing Address - Phone:916-425-7733
Mailing Address - Fax:916-372-2466
Practice Address - Street 1:2101 STONE BLVD STE 175
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-4055
Practice Address - Country:US
Practice Address - Phone:916-425-7733
Practice Address - Fax:916-372-2466
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40879106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist