Provider Demographics
NPI:1356733257
Name:PETER SHOLLEY MFT
Entity type:Organization
Organization Name:PETER SHOLLEY MFT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MFT
Authorized Official - Phone:415-820-3969
Mailing Address - Street 1:779 SUMMERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 CHERRY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4202
Practice Address - Country:US
Practice Address - Phone:415-820-3969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFCC# 53511251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health