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General NPI Number Information
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NPI Number | 1063044535
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Entity Type | Organization
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Legal Business Name | GRACE JEBARA MARRIAGE THERAPY INC
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Dates
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Enumeration Date | 02/12/2020
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Last Update Date | 02/12/2020
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Provider Practice Location Address
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Address Line | 2169 UNION ST # 3
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City | SAN FRANCISCO
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State | CA
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Zip | 94123-4003
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Country | US
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Telephone | 415-891-9562
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Fax |
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Provider Business Mailing Address
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Address Line | 6 SNOWDEN LN
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City | FAIRFAX
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State | CA
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Zip | 94930-1029
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Country | US
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Telephone | 415-891-9562
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | DR. MANUEL A MANOTAS
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Credential | PSY.D
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Telephone | 415-891-9562
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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