Healthcare Provider Details

I. General information

NPI: 1760736458
Provider Name (Legal Business Name): BEHAVIORAL DIRECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 ESMEYER DR
SAN RAFAEL CA
94903-3770
US

IV. Provider business mailing address

131 ESMEYER DR
SAN RAFAEL CA
94903-3770
US

V. Phone/Fax

Practice location:
  • Phone: 415-971-1186
  • Fax: 415-366-1685
Mailing address:
  • Phone: 415-971-1186
  • Fax: 415-366-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-08-4718
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC30244
License Number StateCA

VIII. Authorized Official

Name: ALEX CAMPBELL
Title or Position: PRESIDENT
Credential:
Phone: 415-971-1186