=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225765787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AN INDIVIDUAL MARRIAGE AND RELATIONSHIP THERAPY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2022
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 SHORELINE DR
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94404-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-762-5284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 SHORELINE DR
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94404-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-459-5024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MS. JEANNE PERI SUTTON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 650-762-5284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------