=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285939827
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD GREG MAUTERER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2011
-----------------------------------------------------
Last Update Date | 03/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 BON AIR RD
-----------------------------------------------------
City | GREENBRAE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94904-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-473-6835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 BON AIR RD
-----------------------------------------------------
City | GREENBRAE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94904-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-473-6835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 90576
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT90576
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------