Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003021635 |
---|---|
Provider Name | Sage Mountainfire |
First Address | Ukiah, CA 95482-0464 |
Second Address | Ukiah, CA 95482-5559 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2007 |
Last Update Date | 08/07/2007 |