Healthcare Provider Details

I. General information

NPI: 1679607386
Provider Name (Legal Business Name): CHILD THERAPY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 WASHINGTON AVE
ALBANY CA
94706-1856
US

IV. Provider business mailing address

1480 LINCOLN AVE STE 8
SAN RAFAEL CA
94901-2085
US

V. Phone/Fax

Practice location:
  • Phone: 510-525-6225
  • Fax:
Mailing address:
  • Phone: 415-456-7724
  • Fax: 415-456-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN LUKAS
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 415-456-7724