Healthcare Provider Details

I. General information

NPI: 1952969743
Provider Name (Legal Business Name): SUPPORT NETWORK OF THE BAY AREA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 SUNSHINE DR
PACIFICA CA
94044-1129
US

IV. Provider business mailing address

293 SUNSHINE DR
PACIFICA CA
94044-1129
US

V. Phone/Fax

Practice location:
  • Phone: 415-999-5613
  • Fax:
Mailing address:
  • Phone: 415-999-5613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN JUSTIN NEWSOME
Title or Position: PSYCHOTHERAPIST
Credential: LCSW
Phone: 415-999-5613