Provider Demographics
NPI:1700165172
Name:MCDONALD, COLLEEN RAE (MFT)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:RAE
Last Name:MCDONALD
Suffix:
Gender:F
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:PO BOX 73315
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-3315
Mailing Address - Country:US
Mailing Address - Phone:530-753-3867
Mailing Address - Fax:
Practice Address - Street 1:1818 MOORE BLVD
Practice Address - Street 2:#234
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-7683
Practice Address - Country:US
Practice Address - Phone:530-753-3867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT25034106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist