Healthcare Provider Details

I. General information

NPI: 1326785361
Provider Name (Legal Business Name): CONSCIOUS MARRIAGE AND FAMILY THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 N ST STE N
SACRAMENTO CA
95816-5712
US

IV. Provider business mailing address

1140 WALL ST # 355
LA JOLLA CA
92037-4531
US

V. Phone/Fax

Practice location:
  • Phone: 619-393-2290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SU BOUDREAU
Title or Position: OWNER
Credential:
Phone: 619-393-2290