Provider Demographics
NPI:1811901143
Name:FORMAKER, WILLIAM JAMES (MFT)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JAMES
Last Name:FORMAKER
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 1:606 BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4228
Mailing Address - Country:US
Mailing Address - Phone:707-544-5717
Mailing Address - Fax:707-887-8208
Practice Address - Street 1:606 BEAVER ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4228
Practice Address - Country:US
Practice Address - Phone:707-544-5717
Practice Address - Fax:707-887-8208
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29030106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist