Provider Demographics
NPI:1710184593
Name:SCHREIBER, RUSSELL (MFT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:SCHREIBER
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 1:11000 FALSTAFF RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-9114
Mailing Address - Country:US
Mailing Address - Phone:707-292-4454
Mailing Address - Fax:
Practice Address - Street 1:11000 FALSTAFF RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-9114
Practice Address - Country:US
Practice Address - Phone:707-292-4454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40650106H00000X
CAPSY 23128103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 40650OtherMFT