Provider Demographics
NPI:1700058708
Name:SHECKLER-SMITH, BERT WAYNE (MFT)
Entity Type:Individual
Prefix:MR
First Name:BERT
Middle Name:WAYNE
Last Name:SHECKLER-SMITH
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:MR
Other - First Name:BERT
Other - Middle Name:WAYNE
Other - Last Name:SHECKLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:47 6TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3092
Mailing Address - Country:US
Mailing Address - Phone:707-363-7281
Mailing Address - Fax:
Practice Address - Street 1:47 6TH ST STE 205
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3092
Practice Address - Country:US
Practice Address - Phone:707-363-7281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 28723106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist