=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437580073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA GESTALT INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2013
-----------------------------------------------------
Last Update Date | 01/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 EASY ST SUITE 13
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94043-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-689-6422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 EASY ST SUITE 13
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94043-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-689-6422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. LUCANNA GREY
-----------------------------------------------------
Credential | M.A.
-----------------------------------------------------
Telephone | 415-689-6422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------