Healthcare Provider Details

I. General information

NPI: 1760924658
Provider Name (Legal Business Name): WOMEN'S THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-1108
US

IV. Provider business mailing address

2105 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-1108
US

V. Phone/Fax

Practice location:
  • Phone: 510-524-4822
  • Fax: 510-524-8292
Mailing address:
  • Phone: 510-524-4822
  • Fax: 510-524-8292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LISA PERRY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 510-524-4822