Healthcare Provider Details

I. General information

NPI: 1003953100
Provider Name (Legal Business Name): HUCKLEBERRY YOUTH PROGRAMS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 3RD STREET SUITE G
SAN RAFAEL CA
94901
US

IV. Provider business mailing address

361 3RD STREET SUITE G
SAN RAFAEL CA
94901
US

V. Phone/Fax

Practice location:
  • Phone: 415-258-4944
  • Fax: 415-258-4943
Mailing address:
  • Phone: 415-258-4944
  • Fax: 415-258-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS STYLES
Title or Position: EXECUTIVE DIRECTOR
Credential: PSYD
Phone: 415-668-2622