Provider Demographics
NPI:1649807223
Name:MAGUIRE, MARIA REBECCA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:REBECCA
Last Name:MAGUIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:MAGUIRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3957 LAKEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-7602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319 S E ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5175
Practice Address - Country:US
Practice Address - Phone:707-284-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TRAINEE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health