Provider Demographics
NPI:1669534889
Name:ALTAKER, BRYAN H (MFT)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:H
Last Name:ALTAKER
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 1:2665 SANTA ROSA AVE # 121
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7683
Mailing Address - Country:US
Mailing Address - Phone:510-457-8351
Mailing Address - Fax:707-843-7864
Practice Address - Street 1:2665 SANTA ROSA AVE # 121
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7683
Practice Address - Country:US
Practice Address - Phone:510-457-8351
Practice Address - Fax:707-843-7864
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45632106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist