Healthcare Provider Details

I. General information

NPI: 1629451703
Provider Name (Legal Business Name): BIG DOG COUNSELING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1683 NOVATO BLVD SUITE 1B
NOVATO CA
94947-3200
US

IV. Provider business mailing address

815 CREED RD
OAKLAND CA
94610-1826
US

V. Phone/Fax

Practice location:
  • Phone: 510-427-7785
  • Fax: 510-625-0662
Mailing address:
  • Phone: 510-427-7785
  • Fax: 510-625-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY24459
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24459
License Number StateCA

VIII. Authorized Official

Name: DR. LOUISA PARKS
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 510-427-7785