Healthcare Provider Details

I. General information

NPI: 1174256903
Provider Name (Legal Business Name): CYNTHIA SMITH STEPHAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 LINCOLN AVE STE 105
SAN RAFAEL CA
94901-2141
US

IV. Provider business mailing address

261 PURDUE AVE
KENSINGTON CA
94708-1136
US

V. Phone/Fax

Practice location:
  • Phone: 415-322-0491
  • Fax:
Mailing address:
  • Phone: 415-322-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number163304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: