Healthcare Provider Details

I. General information

NPI: 1811718778
Provider Name (Legal Business Name): DAVID W OLMSTEAD MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HARTE AVE
SAN RAFAEL CA
94901-5221
US

IV. Provider business mailing address

21 HARTE AVE
SAN RAFAEL CA
94901-5221
US

V. Phone/Fax

Practice location:
  • Phone: 662-419-0412
  • Fax:
Mailing address:
  • Phone: 415-935-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number150388
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: