Provider Demographics
NPI:1700068145
Name:EHREDT, MARK (RRW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:EHREDT
Suffix:
Gender:M
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 MISSOURI ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6007
Mailing Address - Country:US
Mailing Address - Phone:707-435-9911
Mailing Address - Fax:707-435-0704
Practice Address - Street 1:1143 MISSOURI ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6007
Practice Address - Country:US
Practice Address - Phone:707-435-9911
Practice Address - Fax:707-435-0704
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARRW101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor