Healthcare Provider Details

I. General information

NPI: 1154112019
Provider Name (Legal Business Name): MS. CAROLINE BOUSSENOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 LINCOLN AVE STE 8
SAN RAFAEL CA
94901-2085
US

IV. Provider business mailing address

7454 ROCKWAY AVE
EL CERRITO CA
94530-3750
US

V. Phone/Fax

Practice location:
  • Phone: 415-456-7724
  • Fax:
Mailing address:
  • Phone: 650-430-4472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number165856
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: