=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932856507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANCA SEVERIN MFT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2022
-----------------------------------------------------
Last Update Date | 03/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 S AMPHLETT BLVD STE 220G
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94402-2713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-407-5115
-----------------------------------------------------
Fax | 800-807-8009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 BRYANT ST UNIT 411461
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94141-1781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-407-5115
-----------------------------------------------------
Fax | 800-807-8009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MFT/OWNER
-----------------------------------------------------
Name | ANCA SEVERIN
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 415-407-5115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------