Provider Demographics
NPI:1255483301
Name:BARON, ROGER (PHD MFT)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BARON
Suffix:
Gender:M
Credentials:PHD MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 TENNESSEE STREET
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590
Mailing Address - Country:US
Mailing Address - Phone:707-643-0258
Mailing Address - Fax:707-643-0115
Practice Address - Street 1:631 TENNESSEE STREET
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590
Practice Address - Country:US
Practice Address - Phone:707-643-0258
Practice Address - Fax:707-643-0115
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC6593106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist