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General NPI Number Information
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NPI Number | 1154713774
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Entity Type | Organization
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Legal Business Name | CHILD THERAPY INSTITUTE OF MARIN
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Dates
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Enumeration Date | 02/19/2015
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Last Update Date | 02/19/2015
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Provider Practice Location Address
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Address Line | 720 SOUTHPOINT BLVD
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City | PETALUMA
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State | CA
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Zip | 94954-7495
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Country | US
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Telephone | 707-237-3644
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Fax |
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Provider Business Mailing Address
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Address Line | 1480 LINCOLN AVE STE 8
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City | SAN RAFAEL
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State | CA
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Zip | 94901-2085
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Country | US
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Telephone |
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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 | DR. BRIAN N LUKAS
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Credential | PHD
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Telephone | 415-456-7724
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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