Healthcare Provider Details

I. General information

NPI: 1386740652
Provider Name (Legal Business Name): NANCY ILENE GUMP MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 SAN ANSELMO AVE SUITE 6
SAN ANSELMO CA
94960-2664
US

IV. Provider business mailing address

407 SAN ANSELMO AVE SUITE 6
SAN ANSELMO CA
94960-2664
US

V. Phone/Fax

Practice location:
  • Phone: 415-453-5333
  • Fax: 415-454-6816
Mailing address:
  • Phone: 415-453-5333
  • Fax: 415-454-6816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC25530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: