# MYCELIUM FAMILY THERAPY, PROFESSIONAL CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Mycelium Counseling Collective
- **Organization subpart:** No

## Provider details

- **NPI number:** 1124957030
- **Authorized official:** LACEY LYNN PALMER PHD, LMFT (PRESIDENT, CEO)
- **Authorized official phone:** (707) 782-2419

## Contact information

- **Practice address:** 1500 VALLEY HOUSE DR STE 210, ROHNERT PARK, CA 94928-4938
- **Practice address phone:** (707) 782-2419
- **Practice address fax:** (707) 715-2875
- **Mailing address:** 1500 VALLEY HOUSE DR STE 210, ROHNERT PARK, CA 94928-4938
- **Mailing address phone:** (707) 782-2419
- **Mailing address fax:** (707) 715-2875

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 104100000X | Social Worker | — | — | — |
| 1041C0700X | Clinical Social Worker | — | — | — |
| 106H00000X | Marriage & Family Therapist | — | NULL | Yes |
| 106H00000X | Marriage & Family Therapist | — | — | Yes |

## Other

- **Enumeration date:** 05/16/2026
- **Last updated:** 07/10/2026