Provider Demographics
NPI:1912302498
Name:ENGLISH, ILENE (MFT)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:ENGLISH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:ILENE
Other - Middle Name:
Other - Last Name:ENGLISH-PAUL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:130 PETALUMA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4220
Practice Address - Country:US
Practice Address - Phone:707-634-4824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34363106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90-0911256OtherEIN