MEDICARE: MS. ROBYN O MATLOCK L.M.F.T.

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	106H00000X	Marriage & Family Therapist	MFC37589	CA

General Provider Information

NPI Number	:	1427187160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ROBYN O MATLOCK L.M.F.T.

Provider Business Mailing Address
First Line	:	49 JOY AVE
Second Line	:	B
City	:	BRISBANE
State	:	CA
Zip	:	94005-1749
Country	:	US
Telephone Number	:	415-994-2630
Fax Number	:	520-505-1255

Provider Business Practice Location Address
First Line	:	1475 HUNTINGTON AVE
Second Line	:	SUITE 201
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-5990
Country	:	US
Telephone Number	:	415-994-2630
Fax Number	:	520-505-1255

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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