Basic Information
| Provider Information | |||||||||
| NPI: | 1306029319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAWSON | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MFT INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 GRAVENSTEIN HWY N | ||||||||
| Address2: | |||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954722607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 GRAVENSTEIN HWY N | ||||||||
| Address2: | |||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954722607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 06/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF # 52460 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.