Healthcare Provider Details

I. General information

NPI: 1184085979
Provider Name (Legal Business Name): BAY PEDIATRIC DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DEERWOOD RD STE 395
SAN RAMON CA
94583-1530
US

IV. Provider business mailing address

111 DEERWOOD RD STE 395
SAN RAMON CA
94583-1530
US

V. Phone/Fax

Practice location:
  • Phone: 415-895-0207
  • Fax:
Mailing address:
  • Phone: 415-895-0207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMFC32136
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberMFC32136
License Number StateCA

VIII. Authorized Official

Name: ANAMERCEDES YEGANEH
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 415-579-2731