Healthcare Provider Details

I. General information

NPI: 1568185619
Provider Name (Legal Business Name): SEA CHANGE PSYCHOTHERAPY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 DONAHUE ST
SAUSALITO CA
94965
US

IV. Provider business mailing address

203 FLAMINGO RD #209
MILL VALLEY CA
94941-4149
US

V. Phone/Fax

Practice location:
  • Phone: 415-967-2025
  • Fax:
Mailing address:
  • Phone: 415-987-1187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TARA L KLINE
Title or Position: PRESIDENT AD CEO
Credential: PSYD
Phone: 415-967-2025