Healthcare Provider Details

I. General information

NPI: 1134341324
Provider Name (Legal Business Name): GLORIA ANNE FREDERICO M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GLORIA ANNE FRUSH M.F.T.

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 OCEAN AVE
SAN FRANCISCO CA
94112-1727
US

IV. Provider business mailing address

213 HILLCREST RD
SAN CARLOS CA
94070-1914
US

V. Phone/Fax

Practice location:
  • Phone: 415-452-2200
  • Fax: 415-334-5712
Mailing address:
  • Phone: 650-508-1530
  • Fax: 650-508-1526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC34997
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: