MEDICARE: THE CHILD THERAPY INSTITUTE OF MARIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1134641731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CHILD THERAPY INSTITUTE OF MARIN

Provider Business Mailing Address
First Line	:	1480 LINCOLN AVE
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-2084
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11100 SAN PABLO AVE STE 205
Second Line	:
City	:	EL CERRITO
State	:	CA
Zip	:	94530-2100
Country	:	US
Telephone Number	:	510-525-6225
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	BRIAN LUKAS
Credential	:
Telephone Number	:	415-456-7724

Provider Enumeration Date	:	07/14/2017
Last Update Date	:	05/20/2025

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