Provider Demographics
NPI:1790976645
Name:MENKE, JOAN MARIE (MFT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:MENKE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:MARIE
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:40 4TH ST
Mailing Address - Street 2:STE. 224
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3040
Mailing Address - Country:US
Mailing Address - Phone:707-769-1215
Mailing Address - Fax:707-763-3920
Practice Address - Street 1:205 KELLER ST
Practice Address - Street 2:STE 202
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2874
Practice Address - Country:US
Practice Address - Phone:707-769-1215
Practice Address - Fax:707-763-3920
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35407106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist