Healthcare Provider Details

I. General information

NPI: 1710550918
Provider Name (Legal Business Name): LIFE BY DESIGN MARRIAGE AND FAMILY THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 SHATTUCK AVE
BERKELEY CA
94704-1210
US

IV. Provider business mailing address

1611 SYCAMORE AVE UNIT 5511
HERCULES CA
94547-6021
US

V. Phone/Fax

Practice location:
  • Phone: 510-646-0046
  • Fax:
Mailing address:
  • Phone: 510-646-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MELODY WRIGHT
Title or Position: PRESIDENT
Credential:
Phone: 510-646-0046