=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457010878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA BOGHRATI MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2021
-----------------------------------------------------
Last Update Date | 06/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 COLLEGE AVE STE 1C
-----------------------------------------------------
City | KENTFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94904-2565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-448-7153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2113
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94942-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 128080
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------