=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285941807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIN OUTPATIENT AND RECOVERY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2010
-----------------------------------------------------
Last Update Date | 02/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 C ST SUITE 8
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-485-6736
-----------------------------------------------------
Fax | 415-236-1830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 C ST SUITE 8
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-485-6736
-----------------------------------------------------
Fax | 415-236-1830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. LINDSAY ERVIN FERGUSON JR.
-----------------------------------------------------
Credential | MS, LMFT
-----------------------------------------------------
Telephone | 415-485-6736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 210033AN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------