MEDICARE: WEST COAST POSTTRAUMA RETREAT

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	323P00000X	Psychiatric Residential Treatment Facility	PSY 18339	CA

General Provider Information

NPI Number	:	1891728267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST POSTTRAUMA RETREAT

Provider Business Mailing Address
First Line	:	4460 - 16 REDWOOD HWY
Second Line	:	SUITE 362
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-1953
Country	:	US
Telephone Number	:	415-721-9789
Fax Number	:

Provider Business Practice Location Address
First Line	:	4460 - 16 REDWOOD HWY
Second Line	:	SUITE 362
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-1953
Country	:	US
Telephone Number	:	415-721-9789
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOEL FAY
Credential	:	PSY.D.
Telephone Number	:	415-720-6653

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	08/22/2020

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