Healthcare Provider Details

I. General information

NPI: 1114324167
Provider Name (Legal Business Name): GREGORY ROBERT TOMPKINS MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

IV. Provider business mailing address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

V. Phone/Fax

Practice location:
  • Phone: 415-507-4209
  • Fax:
Mailing address:
  • Phone: 415-507-4209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAMFT112495
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: