=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033932215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILD THERAPY INSTITUTE OF MARIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1035 SAN PABLO AVE STE 8
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94706-2277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-456-7724
-----------------------------------------------------
Fax | 415-456-1050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1480 LINCOLN AVE STE 8
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-2085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-456-7724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | LUCELLE HOEFNAGELS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-456-7724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------