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General NPI Number Information
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NPI Number | 1134275589
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Entity Type | Organization
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Legal Business Name | CENTER FOR RESTORATIVE PRACTICE
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 08/13/2020
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Provider Practice Location Address
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Address Line | 639 DRAKE AVE.
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City | MARIN CITY
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State | CA
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Zip | 94965
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Country | US
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Telephone | 707-322-4971
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1435
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City | SAUSALITO
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State | CA
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Zip | 94966-1435
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Country | US
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Telephone | 707-322-4971
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. MARCUS H SMALL
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Credential | LMFT
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Telephone | 707-322-4971
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 39843305
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License Number State | CA
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