Healthcare Provider Details

I. General information

NPI: 1265377204
Provider Name (Legal Business Name): ELLEN BAINER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 SUNSET LN STE D
ANTIOCH CA
94509-6124
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: