=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629451703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIG DOG COUNSELING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2015
-----------------------------------------------------
Last Update Date | 08/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1683 NOVATO BLVD SUITE 1B
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-427-7785
-----------------------------------------------------
Fax | 510-625-0662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 CREED RD
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94610-1826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-427-7785
-----------------------------------------------------
Fax | 510-625-0662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LOUISA PARKS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 510-427-7785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY24459
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY24459
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------