Healthcare Provider Details

I. General information

NPI: 1780409219
Provider Name (Legal Business Name): CHILD THERAPY INSTITUTE OF MARIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 BERKELEY WAY # 5
BERKELEY CA
94704-1007
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: 415-456-7724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LUCELLE HOEFNAGELS
Title or Position: ADMINISTRATION
Credential:
Phone: 415-456-7724