Provider Demographics
NPI:1841605961
Name:WILLIAM J. FORMAKER, MFT
Entity Type:Organization
Organization Name:WILLIAM J. FORMAKER, MFT
Other - Org Name:FULL HEART TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:707-544-5717
Mailing Address - Street 1:606 BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4228
Mailing Address - Country:US
Mailing Address - Phone:707-544-5717
Mailing Address - Fax:707-887-8288
Practice Address - Street 1:606 BEAVER ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4228
Practice Address - Country:US
Practice Address - Phone:707-544-5717
Practice Address - Fax:707-887-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT29030106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty