Healthcare Provider Details

I. General information

NPI: 1619581337
Provider Name (Legal Business Name): FAMILY TREE PSYCHOLOGY GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 GRAND AVE
OAKLAND CA
94610-2009
US

IV. Provider business mailing address

3655 GRAND AVE
OAKLAND CA
94610-2009
US

V. Phone/Fax

Practice location:
  • Phone: 510-858-7649
  • Fax:
Mailing address:
  • Phone: 510-858-7649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CARMELINDA M MANN
Title or Position: CEO
Credential: PHD
Phone: 415-515-6234