Healthcare Provider Details

I. General information

NPI: 1033990411
Provider Name (Legal Business Name): LOST COAST PSYCHOTHERAPY LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1178 BROADWAY FL 3
NEW YORK NY
10001-5666
US

IV. Provider business mailing address

14 SAN CARLOS AVE
EL CERRITO CA
94530-4147
US

V. Phone/Fax

Practice location:
  • Phone: 929-262-0794
  • Fax:
Mailing address:
  • Phone: 707-489-8814
  • 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: MICHAEL WALDON
Title or Position: OWNER
Credential: LCSW
Phone: 707-489-8814