Provider Demographics
NPI:1710055728
Name:NUMOTO, BRUCE RICHARD (MFT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RICHARD
Last Name:NUMOTO
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 D ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-6017
Mailing Address - Country:US
Mailing Address - Phone:530-671-3427
Mailing Address - Fax:530-671-3877
Practice Address - Street 1:103 D ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-6017
Practice Address - Country:US
Practice Address - Phone:530-671-3427
Practice Address - Fax:530-671-3877
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 31604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist