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General NPI Number Information
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NPI Number | 1568185619
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Entity Type | Organization
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Legal Business Name | SEA CHANGE PSYCHOTHERAPY INCORPORATED
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Dates
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Enumeration Date | 09/23/2022
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Last Update Date | 09/23/2022
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Provider Practice Location Address
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Address Line | 164 DONAHUE ST
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City | SAUSALITO
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State | CA
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Zip | 94965
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Country | US
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Telephone | 415-967-2025
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Fax |
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Provider Business Mailing Address
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Address Line | 203 FLAMINGO RD #209
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City | MILL VALLEY
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State | CA
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Zip | 94941-4149
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Country | US
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Telephone | 415-987-1187
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Fax |
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Authorized Official
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Title or Position | PRESIDENT AD CEO
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Name | DR. TARA L KLINE
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Credential | PSYD
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Telephone | 415-967-2025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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