Provider Demographics
NPI:1801219837
Name:OMAHA, JOHN (MFT)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:OMAHA
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:PO BOX 1531
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-1531
Mailing Address - Country:US
Mailing Address - Phone:707-527-8089
Mailing Address - Fax:
Practice Address - Street 1:320 10TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5291
Practice Address - Country:US
Practice Address - Phone:707-545-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 53673106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist