Provider Demographics
NPI:1306161617
Name:MAILLO, JUAN (LMFT #103938)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:MAILLO
Suffix:
Gender:M
Credentials:LMFT #103938
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 4TH ST # 5076
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4057
Mailing Address - Country:US
Mailing Address - Phone:415-275-0307
Mailing Address - Fax:
Practice Address - Street 1:1275 4TH ST # 5076
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4057
Practice Address - Country:US
Practice Address - Phone:415-275-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA103938106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor