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General NPI Number Information
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NPI Number | 1720794712
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Entity Type | Individual
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Provider Name | KIM STAFFORD FAHLEN LMFT
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Gender | Female
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Dates
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Enumeration Date | 01/24/2023
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Last Update Date | 01/24/2023
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Provider Practice Location Address
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Address Line | 875 4TH ST STE 6
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City | SAN RAFAEL
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State | CA
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Zip | 94901-3242
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Country | US
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Telephone | 415-578-2978
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Fax |
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Provider Business Mailing Address
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Address Line | 23 HACIENDA CT
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City | SAN RAFAEL
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State | CA
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Zip | 94901-1314
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Country | US
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Telephone | 415-205-4034
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 41746
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License Number State | CA
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