MEDICARE: GREGORY MICHAEL TILDEN LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	APCC5424	CA
2	106H00000X	Marriage & Family Therapist	125005	CA

General Provider Information

NPI Number	:	1245710078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY MICHAEL TILDEN LMFT

Provider Business Mailing Address
First Line	:	500 PETALUMA AVE
Second Line	:
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-4216
Country	:	US
Telephone Number	:	203-843-1680
Fax Number	:

Provider Business Practice Location Address
First Line	:	11100 SAN PABLO AVE STE 205
Second Line	:
City	:	EL CERRITO
State	:	CA
Zip	:	94530-2100
Country	:	US
Telephone Number	:	510-859-4889
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	04/13/2021

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